Before and After - The Gold Standard pt. 1

One thing I've been curious about throughout the entirety of paramedic school so far is how much my perceptions of medicine will change from the beginning of the program to the end. So to keep track of some of those changes in my opinion (or lack thereof, as the case may be), I'm going to do a before and after post on certain topics that I feel are most subject to change.

The topic of this one: intubation.

Before we start, let me tell you a little bit about my experience with intubation. My first experience with airway management was during our OR rotations about a month ago, and it included bagging, LMA insertion, and endotracheal intubation. So far I've successfully intubated twenty-two patients without any incidences of esophageal or right main-stem intubation. I've never tubed a critical patient, or one outside of the OR. So my experience is pretty limited.

I like to try and stay fluid in my opinions, because medicine is certainly NOT a static profession to work in, and perhaps by the time I'm done with field internship and the program in general my views on endotracheal intubation will change. Above all else, I hope that wherever I stand, I always do what's right for my patient and not necessarily what's right for me.

Before
As of right now, I am a proponent of prehospital intubation. This is a controversial topic in the field of EMS, as numerous studies are out now that show a lack of correlation between prehospital intubation and increased survival to discharge rates. I won't bore you with a list of studies, but you can find tons of them online with little difficulty that range from advocating eliminating prehospital endotracheal intubation all together, to limiting it to medical patients only, to studies that actually seem to support it in the right hands. The unfortunate thing about such scientific studies is that a lot of the results are often very situational; was the intubating paramedic experienced in intubation? what was the patient's mortality to begin with? and so on and so forth.

Is intubation appropriate for all patients? No, not at all. Are there patients that DO benefit from prehospital intubation? Yes! Any paramedic can give you his anecdote of the patient he or she tubed that they saw three months later at the grocery store alive and talking. Furthermore, the current research seems to suggest that medical non-arrest patients DO benefit from intubation. The biggest determining factor seems to be experience and method of intubation. A recent study released on JEMS showed that paramedics in the prehospital setting interrupted chest compressions during CPR for far too long during intubation. Now, we can take that as a call to eliminate prehospital intubation all together, or we can address the problem itself and correct it by not interrupting compressions during intubation. Would that make a difference? Theoretically, yes. If the problem with intubation during CPR is that paramedics are interrupting CPR for too long to tube the patient, then the easy solution is to simply not interrupt CPR during the procedure. That is the gold standard of intubation during arrest for many services, including the one I work for.

Another question that I've unfortunately been unable to get a very solid response to is whether or not endotracheal intubation is appropriate in ANY setting outside of the OR. If anyone's been able to find out mortality rates for patients intubated in the ER, please share them with me. I have a feeling that if it's bad in the prehospital setting, it's probably bad in the ER as well. Because of the critical nature of both of our patients, the setting is generally the same; however unlike the ER, we in EMS may not necessarily have quite as many hands available to assist as they do. The other factor is the educational level of the providers involved. We all know how difficult it can be to get experience in the OR intubating patients, especially when you're competing against CRNA and medical students, so if the evidence shows that if a paramedic is not capable of intubating due to lack of experience, the solution then becomes additional education.

The move towards blind-insertion airways is quickly gaining momentum, and while I can find no fault inherent in the procedure itself, I have to ask whether we're making any more of a difference in using a combitube over an endotracheal tube when the patient will in fact be endotracheally intubated upon arrival to the ER. If emergent endotracheal intubation is inherently bad in and of itself, regardless of factors such as experience level of the provider or location, then why is it practiced anywhere outside of the OR? It seems to me that, if it's bad in an emergent patient outside of the hospital, it would also be bad for an emergent patient inside the ER as well. In which case, perhaps all of us in the realm of emergency medicine should be switching to dual-lumen airways. I haven't been able to find a study that addressed this, but I'd be interested to know what kind of complications and airway damage result from being intubated with a combitube, followed shortly thereafter by having the tube pulled and an endotracheal tube placed.

In conclusion, there are tremendous hurdles ahead of EMS that we must address to increase our ability to care for our patients safely and adequately, one of them being endotracheal intubation. Right now, it is considered the gold standard of airway management. Unlike bagging, you isolate the trachea and prevent gastric distention, and unlike dual-lumen airways it is still the number one choice in the ER, and in the hands of an experienced and knowledgeable paramedic, can be safely performed in the prehospital setting. Time will tell whether the procedure should be held off on all together in all emergency patients, but until then, I maintain the stance that if done correctly and at the right time, it is no more dangerous than inserting a blind-airway device. Does every patient need to be tubed? No, of course not. Should arrest patients be tubed at all? Maybe not. For now, it is the gold standard of airway management. Like all things in medicine, however, it is just a tool that aids us now; in the future, our descendants may laugh at the idea of inserting ANY kind of tube into a patient's mouth to assist ventilations, just as we laugh at our ancestors' notion of the four humors.

Above all else, in the midst of such controversy regarding prehospital airway management, I hope that none of us come to the conclusion that we, as paramedics, are defined by our ability to do any one procedure. We are defined as the highest level providers of emergency medical care in the prehospital arena, and that is the standard we should meet: to provide the highest level of care possible to our patients. If the highest level of care no longer includes intubation, then by eliminating it we live up to our definition.

When I finish my internship, I will write part 2 of this Before and After, and let you all know how my views have changed (or stayed the same) with a little more experience under my belt.