Systematic Review of Prehospital Airway Management

[E tank]

I realize that it is a wildly unpopular view, but I have never felt that the psychomotor skill of intubation to be that difficult, especially since the advent of field video laryngoscopy end tidal capnography.

I will agree that airway management as a package is somewhat more complicated and deserves probably a bit more standardized education than it is currently given.

I've always hated that term "psychomotor skill". It is applied to everything from changing an occupied bed to, in this case, intubation, and as such has the effect of reducing critical interventional therapies to equivalency with far less critical therapies.

That said, you're absolutely correct, the " psychomotor skill" of intubation isn't that difficult. And if it were just laryngoscopy and tube placement in well lit, climate controlled stable patients, there would be no problem.

 

[SandpitMedic]

...until it’s needed. Taking away intubation is like taking guns away from police. Sounds solid and amazing and prevents so many tragedies, right until reality happens and you really need a gun.

Proper training and system design can safely field ETI.

I agree with this. This is one important EMS tool. Improper airway management training/experience is a symptom, not the disease affecting paramedics. The disease is that there are (in most places and almost every urban area) 1.) Too many paramedics. 2.) Not enough educational requirements to become a paramedic. 3,) Not enough hands on CE to include airway mgmt.

Taking a life saving skill away from the many due to the poor performers is not the way to do it. Holding them accountable and changing the structure of the training model is. (Circle back to EMS degrees=more clinical time and training).

I also agree that if intubation is in the kit... then all the other neccesities are in the kit as well including proper planning and execution, full RSI, back ups including step down and step up, and continual airway training.

 

[SandpitMedic]

say it a little louder for the people in the back who aren't listening and insist that every patient deserves a paramedic....

This! 9/10 times no medic is needed.

So how many live intubations do they [flight medics] actually perform in a shift? in a month? in a year?

When I was doing flight I was averaging about 2-3 tubes a month working ~10 shifts a month. Sometimes more, sometimes less. Many more patients were already intubated, yes.

We also had quarterly labs which included airway/vent management and performing intubations on peds and adult mannequins with VL and DL. We also had annual cadaver labs where we practiced surgical crics, chest thoracostomy, and esharotomy. We were held to a standard, and if you did not meet the standard you were remediated.

 

[Carlos Danger]

Wouldn't you say that's true of medicine in general?

From what I've seen it is MUCH more true in EMS than healthcare in general

The initial number for baseline competency is north of 40, if I recall correctly. There is a lot of research on determining competency.

If we're thinking about the same study, it was done on EM residents and I believe it was 40 or 50 tubes for basic competence and at least 90 tubes for "mastery". Those numbers have been used to develop minimum numbers for residency programs and credentialing requirements but I don't think have ever really been validated with repeated studies.

Personally, I think you can achieve a minimal level of competence with fewer than 40 tubes, but mastery probably takes several hundred and true expertise requires both focused academic study and managing at least a couple thousand airways of all different types using different methods.

 

[CANMAN]

This! 9/10 times no medic is needed.


When I was doing flight I was averaging about 2-3 tubes a month working ~10 shifts a month. Sometimes more, sometimes less. Many more patients were already intubated, yes.

We also had quarterly labs which included airway/vent management and performing intubations on peds and adult mannequins with VL and DL. We also had annual cadaver labs where we practiced surgical crics, chest thoracostomy, and esharotomy. We were held to a standard, and if you did not meet the standard you were remediated.

This..... Personally I intubate more frequently at my flight job then I did while also working at my 911 side job I just left after 12 years. Most of the places we fly for scene work don't have RSI, and there are many times we intubate for IFT's where it hasn't been done already for a multitude of reasons. Most of my 911 arrests got King LT's, we didn't have RSI, and with CPAP the number of field intubation attempts for the average 911 provider is way down. So yes CC and flight medics do get to intubate. We also go to the O.R. if needed but get most of our quarterly intubations in our trauma bay.

 

[silver]

From what I've seen it is MUCH more true in EMS than healthcare in general


If we're thinking about the same study, it was done on EM residents and I believe it was 40 or 50 tubes for basic competence and at least 90 tubes for "mastery". Those numbers have been used to develop minimum numbers for residency programs and credentialing requirements but I don't think have ever really been validated with repeated studies.

Personally, I think you can achieve a minimal level of competence with fewer than 40 tubes, but mastery probably takes several hundred and true expertise requires both focused academic study and managing at least a couple thousand airways of all different types using different methods.

And thats if you are ok accepting 90-95% success rate as being competent.

 

[VFlutter]

I average 2 to 4 RSI most months with a decent increase in the summer months. Most are fairly straight forward but I feel like we see a decent amount of less than ideal airways.

We actually RSI in-hospital about as much as pre-hospital. Many of the ERs we fly out of prefer to defer to the flight crews if able and will try everything they can to avoid it, for better or worse. As opposed to EMS which is commonly on their third attempt, knowing we were 5 minutes away, because they wanted to "take a look". Feels like 90% of our pre-hospital intbuations are prior failed attempts.

 

[SandpitMedic]

I average 2 to 4 RSI most months with a decent increase in the summer months. Most are fairly straight forward but I feel like we see a decent amount of less than ideal airways.

We actually RSI in-hospital about as much as pre-hospital. Many of the ERs we fly out of prefer to defer to the flight crews if able and will try everything they can to avoid it, for better or worse. As opposed to EMS which is commonly on their third attempt, knowing we were 5 minutes away, because they wanted to "take a look". Feels like 90% of our pre-hospital intbuations are prior failed attempts.

Sounds about on par with my experiences. HEMS is a small world but mostly the same everywhere it seems.

 

[DrParasite]

To follow up with my question: why are the ground ambulance people not intubating? or was it not indicated on the ground, but it was in the air? or did they not need intubation on the ground, but they deteriorated? I remember being told by an EMT back in 2001 that every trauma patient gets RSIed once they get into the helicopter.... I later found (from a flight medic) that statement was grossly overstated...

or was it simply the ground medics do they not have the ability to RSI? could (in theory, I know there is all the scope of practice and transfer of care issues) you have RSIed the patient, and then they went by ground ambulance to the hospital?

 

[VFlutter]

To follow up with my question: why are the ground ambulance people not intubating? or was it not indicated on the ground, but it was in the air? or did they not need intubation on the ground, but they deteriorated? I remember being told by an EMT back in 2001 that every trauma patient gets RSIed once they get into the helicopter.... I later found (from a flight medic) that statement was grossly overstated...

or was it simply the ground medics do they not have the ability to RSI? could (in theory, I know there is all the scope of practice and transfer of care issues) you have RSIed the patient, and then they went by ground ambulance to the hospital?

An accurate answer probably depends on the region and protocols. In my area very few ground medics have RSI. Other places that is more common.

But generally speaking...
1. Many patients may need intubation for various reasons but are better served being performed with paralytics that are unavailable with ground. I.e they are not GCS 3 or in Cardiac Arrest
2. Even if a ground service does have RSI they may not always have the experience, education, and equipment that the flight crew may have
3. Things do change and patients can deteriorate quickly.
4. Many flight crew will err on being aggressive with airways, if there is a doubt most will go ahead and RSI before flying. Not every trauma patient needs intubation but if they are combative, will likely be going to the OR and have other issues, sometimes it is preferred to just get it done. Especially in smaller airframes that make it difficult to perform in flight or when the patient's extremities can access the pilot compartment.

If I RSI the patient they are flying with me unless their is some safety or weather issue. If they needed RSI then they likely would benefit from a quicker transport. Plus my helicopter has all my equipment and supplies that the ambulance likely does not.

 

[Carlos Danger]

4. Many flight crew will err on being aggressive with airways, if there is a doubt most will go ahead and RSI before flying. Not every trauma patient needs intubation but if they are combative, will likely be going to the OR and have other issues, sometimes it is preferred to just get it done. Especially in smaller airframes that make it difficult to perform in flight or when the patient's extremities can access the pilot compartment.

If I RSI the patient they are flying with me unless their is some safety or weather issue. If they needed RSI then they likely would benefit from a quicker transport. Plus my helicopter has all my equipment and supplies that the ambulance likely does not.

This is one of the major issues that I have with HEMS and with prehospital intubation.

I know what it is like. I was in HEMS for quite a while. I worked for programs that prided themselves on being "aggressive" with managing airways. At one program in particular, we intubated everybody. Then I started doing a lot of QA and saw what a large percentage of the patients that we intubated were discharged within 24 hours of arrival. They didn't even need to go to a trauma center, never mind be flown, nevermind be intubated. This was years ago so I don't remember numbers, but I want to say it was the better part of 50%. Another significant percentage were extubated within 24 hours of arrival. We weren't helping these people at all; we were exposing them to unnecessary risk.

Also, we all know that % of patients in whom HEMS transport can be shown to be beneficial is dismally low, and that the associated costs are exorbitant. Likewise, we also know that overall, the % of patients intubated in the field who can be shown to benefit from it is very small. With those facts in mind, routinely using HEMS to intubate is pretty much unconscionable, IMO.

I'm not dogging you or your program at all, VFlutter. Like I said, it's the way I was taught too. It's pretty much universal, it seems. But that doesn't make it right.

 

[CANMAN]

This is one of the major issues that I have with HEMS and with prehospital intubation.

I know what it is like. I was in HEMS for quite a while. I worked for programs that prided themselves on being "aggressive" with managing airways. At one program in particular, we intubated everybody. Then I started doing a lot of QA and saw what a large percentage of the patients that we intubated were discharged within 24 hours of arrival. They didn't even need to go to a trauma center, never mind be flown, nevermind be intubated. This was years ago so I don't remember numbers, but I want to say it was the better part of 50%. Another significant percentage were extubated within 24 hours of arrival. We weren't helping these people at all; we were exposing them to unnecessary risk.

Also, we all know that % of patients in whom HEMS transport can be shown to be beneficial is dismally low, and that the associated costs are exorbitant. Likewise, we also know that overall, the % of patients intubated in the field who can be shown to benefit from it is very small. With those facts in mind, routinely using HEMS to intubate is pretty much unconscionable, IMO.

I'm not dogging you or your program at all, VFlutter. Like I said, it's the way I was taught too. It's pretty much universal, it seems. But that doesn't make it right.

I don't think it's like this everywhere, but I do agree that the thought process seems fairly universal. In the two programs I have worked for we certainly do our share of RSI's but they are agreed upon by both crew members based on assessment findings, not indicators like "they may go to the O.R.". We all know the patient's who are likely going to be intubated at some point during their admission, but if they don't need it during our interaction and we can safely defer until we get to our hospital we usually do. Side-stream ETCO2 and an NP airway for certain patients like our borderline obtunded CVA's that still have an intact cough/gag is fine by me and I am comfortable monitoring that and deferring an intubation for the time savings provided we are maintaining sat's and ETCO2 is within acceptable parameters.

 

[Tigger]

The folks I know that fly here get more tubes in the hospital that the field (one is based at an hospital that has no night intensivist so they do all the intubating in the unit at night). It's been a long time since the helicopter has come to intubate a patient for us, it's either done or they are as content as I was to leave the airway alone. Small airframes out here too.