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Monday, June 1, 2015

Guest Post - Perhaps Paramedics Should NOT Intubate!


What if we're wrong? What if the "gold standard" for airway management is not approriate for EMS personnel? Even though many of us spent  untold hours training to perform ET intubation, and have felt justifiable pride in performing this skill well, is it possible that our efforts have been (ahem) misplaced?

This is a guest post by Ben Dowdy, NRP, exploring this unpopular position, reevaluating the opposite perspective. This is part of the inaugural "What-if-We’re-Wrong-a-Thon" organized by Brandon Oto of EMS Basics fame (and soon-to-be lead author in a Very Important Journal).


The continued role of endotracheal intubation as a standard prehospital skill continues to be debated, sometimes hotly.  I’m going to present an argument against prehospital endotracheal intubation.
Aspiration Prevention
Proponents of endotracheal intubation often use the argument that ET intubation protects the airway from aspiration.  But how true is such a claim?  Multiple studies of emergency airway management list aspiration as an infrequent complication 1,2, only occurring 2.8-3.5% of the time.  A study of prehospital RSI3 found that pre-intubation evidence of aspiration was noticed in a significant number of patients, but only one incidence of peri-intubation aspiration was recorded, and no instances of post-intubation aspiration were reported.
What to make of this?  Aspiration pneumonia is a serious diagnosis, conferring an adjusted 2.3 odds ratio in favor of mortality4.  But for the majority of patients having their airway managed in the prehospital field, if aspiration is going to occur, it’s extremely likely that it happens prior to EMS providers arriving and managing the airway.  A prehospital ET tube prevents aspiration very uncommonly.
No Mortality Benefit
As EMS evolves, we’re constantly being challenged to ensure that our treatments and procedures have meaningful, patient-oriented outcomes.  As I heard it referred to early in my paramedic career, “we should be doing things for patients, not to them.”  For prehospital intubation, unfortunately, that does not appear to be the case.  The available literature investigating prehospital intubation’s effects on mortality5-9 overwhelmingly show that if trauma patients are alive when they’re intubated in the field, their chance of dying just increased.  For patients who are already in cardiac arrest, evidence is conflicting as to whether ANY advanced airway management improves mortality, and even then the champion between supraglottic airways and endotracheal intubation varies with almost every new study that comes out.
Can EMS Education Programs Assess Competency in Intubation?
Initial requirements for intubation training in EMS used to be laughable under the National Standard Curriculum; 5 intubations was all you needed, compared with 50+ in medical schools.  The National EMS Education Standards thankfully replaced this with the more blanket term of “demonstrating competency” during providers’ initial training programs, allowing educational institutions to set the bar higher to ensure that new paramedics could competently intubate patients.  However, this higher standard has created difficulties.  A series of surveys10 distributed by the Committee for Accreditation of EMS Programs (CoAEMSP) found that 53% of programs have difficulty obtaining access to ORs for students to practice; 81% use high-fidelity simulators to determine competency and 90.7% urged CoAEMSP to allow these simulators as a means of demonstrating competency.  In others words, most EMS education institutions can’t ensure that their paramedic graduates will ever intubate an actual person, even a stable one undergoing elective surgery, prior to getting their certification or licensure.  To add even greater concern, the available airway mannequins commonly used in EMS airway training (including the ones that most programs want to use to “prove” competency) correlate extremely poorly with airway measurements of actual people11.
Summary
Endotracheal intubation is a skill that’s difficult to master; it takes a lot of realistic practice during initial education and at frequent intervals afterwards to be able to succeed in prehospital settings.  Our education institutions can’t guarantee that providers entering the field can competently intubate patients.  The common argument of “aspiration protection” is a false one; aspiration doesn’t occur very often at all during emergency airway management, it occurs before we ever show up.  When we intubate people, their mortality rate increases.  It’s time to stop using endotracheal intubation as a first-line airway management technique until we can prove that we’re doing it for our patients, instead of to them.
References
1.     Thibodeau LG, et al (1997).  “Incidence of Aspiration after Urgent Intubation.”  Am J Emerg Med. 1997 Oct;15(6):562-5.
2.     Martin LD, et al (2011).  3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications.”  Anesthesiology. 2011 Jan;114(1):42-8.
3.     Vadeboncoeur TF, et al (2006).  The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation.”  J Emerg Med. 2006 Feb;30(2):131-6
4.     Lanspa MJ, et al (2015).  “Characteristics associated with clinician diagnosis of aspiration pneumonia: a descriptive study of afflicted patients and their outcomes.”  J Hosp Med.  2015 Feb; 10(2):90-6.
5.     Evans CC, et al (2013).  “Prehospital non-drug assisted intubation for adult trauma patients with Glasgow Coma Score less than 9.”  Emerg Med J. 2013 Nov;30(11):935-41.
6.     Karamanos E, et al (2014).  “Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury?  A matched cohort analysis.”  Prehosp Disaster Med. 2014 Feb;29(1):32-6.
7.     Taghavi S, et al (2014).  “Prehospital intubation does not decrease complications in the penetrating trauma patient.”  Am Surg. 2014 Jan;80(1):9-14.
8.     Kempema J, et al (2015).  Prehospital endotracheal intubation vs. extraglottic airway device in blunt trauma.”  Am J Emerg Med. 2015 Apr 29.
9.     Stockinger ZT, McSwain NE Jr. (2004).  “Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation.”  J Trauma. 2004 Mar;56(3):531-6.
10.  Kalish, MA (2013).  “Definition of Airway Competency.”  http://coaemsp.org/Documents/Airway-Competency-Kalish-2013-09.pdf
11.  Schebesta K, et al (2012).  “Degrees of reality: Airway Anatomy of High-fidelity Human Patient Simulators and Airway Trainers.”  Anesthesiology.  2012 June;116(6):1204-9.
Bio: Ben Dowdy B.S., NRP, is a paramedic and EMS educator currently working in northern Idaho.  His past experiences include working as a paramedic, tactical paramedic, and SAR medic in urban, rural, and wilderness areas, including Yellowstone National Park, and teaching EMS topics for a university-based EMS education program, as well as across the US and abroad for Wilderness Medical Associates.

32 comments:

  1. I would just like to comment that my medical school required ZERO intubations to successfully graduate. The vast majority of my airway management training and experience came from my time as a prehospital provider. I performed about 30 intubations as a medical student purely due to an anesthesia elective I chose to do while many of my classmates did none. Additionally, I am glad that some things in medicine and EMS in particular are moving towards evidence based recommendations, but I am certain that we are going to start taking away interventions from subsets of patients who would benefit from them. Despite well designed studies, there are going to be particular patients who benefit from a treatment despite statistical evidence to the contrary. There will be patients for whom the most appropriate airway intervention is endotracheal intubation. Our efforts now should be defining those particular populations and ensuring the skill sets of paramedics old and new are top notch, not heavy-handily prohibiting procedures.

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    Replies
    1. Good to hear from a Downeaster!

      I'll emphasize that this is Ben's essay, but the ET question is tough. As the frequency of a procedure goes down, the risk of inappropriate patient selection goes up, procedural complications get more common, and the whole risk:benefit calculation gets trickier.

      Take the example of trauma thoracostomy. Is it a bad thing that medics do not perform this very low frequency (but high acuity) procedure? Certainly there are subsets of patients that would benefit from a quick prehospital thoracostomy, but few systems will see a benefit in training for, and maintaining, proficiency in this skill.

      So, is ET intubation becoming more like thoracostomy, or will it continue to be an essential EMS skill like BVM?

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  2. Another thought provoking post. It seems to be throwing the baby out with the bathwater though. Seriously though, how am I ever supposed to give epi in cardiac arrest if we can't intubate?!

    "It’s time to stop using endotracheal intubation as a first-line airway management technique." Stop it. Right there. That's all you need to say. Don't remove the skill. Don't say paramedics shouldn't perform the skill. We need to stop referring to intubation as the gold standard for airway management. An airway the oxygenates, and ventilates, is the gold standard for airway maintenance. If we keep perpetuating the belief that intubation is the gold standard for airway management, then we will continue to have this debate. Nowhere is this better illustrated than in the OR rotations dilemma. You know what else you miss out on when you don't attend the OR? Mask ventilation on a live patient. LMA insertion on a live patient. Sedation and analgesia on a live patient.

    Additionally, I am yet to find any learning theory that places competency at the same level as mastery. Competency doesn't even signify proficiency. Pick any skill, in any discipline, taught in any initial education program. You don't walk out the door as a master plumber or a master electrician. Why is EMS any different?

    ReplyDelete
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  4. Well explained the different aspects of ET incubation. You have made some good points over here. As you said, Endotracheal intubation is a skill that’s difficult to master. I agree with this point. Essay writing service

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  5. Allow me to play Devil's advocate here, poorer outcomes do not always mean poor care. Given proper use of ETCO2 for airway management and CPAP to try and eliminate unnecessary intubations it would lead one to look at the fact that these patients are likely sicker than the average patient. I do think we need to remove any stigma from choosing an effective SGA over ET Intubation in the field though. Right tool at the right time, as it were. I will say not all Medics should be intubating and video laryngeosopy should be the standrd of care as well.

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  6. I have tubed numerous patients in the field, but each intubation is pretty close to a death sentence as very few patients ever made it out of the hospital. Intubation becomes a stumbling block for paramedics in cardiac arrest as they get tunnel vision towards getting a tube and less intersted in performing good CPR. What could you not accomplish better and easier with an LMA or dual lumen airway device?

    ReplyDelete
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