If you've been in EMS long enough, you can trace your roots back to the days when you sat in complete awe as Johnny and Roy did amazing clinical feats in the dining rooms of fancy restaurants.  Imagine, placing a scary looking light-tipped blade into the patient's mouth and skillfully threading a plastic tube into the patient's throat to breathe for them.  This almost always lead to a miraculous recovery and a picnic with the patient and his family at the end of the show.

Since those early days, endotracheal intubation has been the gold standard for airway management and arguably, the 'Merit Badge' for EMS providers.  Everyone aspired to it.  It secured the airway, provided a medication route and placed a check mark in the correct column.  Add the evolution of RSI, needle cricothyrotomy, and surgical cricothyrotomy and we medics have a whole cadre of advanced airway techniques at our disposal.

Now, along comes the American Heart Association's Emergency Cardiac Care Committee with Guidelines 2005 and it's recommendations place the whole concept of endotracheal intubation in the 'heart' of heated controversy in EMS systems across the country.  The controversy centers on the following two simple, but staggering statements:

o         “The endotracheal tube was once considered the optimal method of managing the airway during cardiac arrest. It is now clear, however, that the incidence of complications is unacceptably high when intubation is performed by inexperienced providers or monitoring of tube placement is inadequate.”

o         “Studies comparing outcomes of out-of-hospital cardiac arrest in adults treated by either emergency medical technicians or paramedics failed to show a link between long-term survival rates and paramedic skills such as intubation, intravenous cannulation, and drug administration.”[i]

The AHA leaves a significant question unanswered in the 2005 Guidelines - namely, what constitutes 'experience'.  The omission of this definition is masterful on the part of the AHA.  The definition is obviously is up to the local medical authority.

This addresses some of the quiet conversations that have been occurring in Medical Director meetings and conferences for the past several years.  The scientific evidence is prevalent.  Studies in Pittsburgh, Ohio, San Diego and other locations indicate that the skill proficiency rates for intubation are low, and by the way, the presence or absence of advanced airway techniques don't seem to make a difference in patient outcomes. Oh, and one more thing, the administration of certain medications through an ET tube, that doesn't work either.

So, what are EMS system administrators to do?  If you believe the studies, and want to follow the AHA recommendations, changes should be made.  Better yet, if you've been honestly tracking your cardiac arrest outcomes and airway proficiency rates, you may KNOW changes need to be made.  Our EMS system recently began the harrowing process of revising the airway management protocols.  The goal is to de-emphasize the role of ETI as the first line ALS airway intervention (especially in light of a consistent 50% procedural success rate for most providers) and emphasize simpler, faster airway management using adjuncts such as a Combitube®.  As you might imagine, the change was met with more than a little resistance.

As you begin the deliberation of your airway management protocols based on the new recommendations from the AHA, here are a few things to consider. 

Track proficiency rates.  If you are not carefully tracking the proficiency rates, start now!  The proficiency needs to be measured on at least two parameters - procedure and outcome.  Procedurally means how many attempts did it take to successfully intubate the patient.  If the patient was successfully intubated on the second attempt, the procedural proficiency is 1/2 or 50%.  The outcome basis measures whether or not a patient who needed intubation, got intubated.  If you had 100 patients who needed to be intubated and 93 were (eventually) successfully intubated, your outcome success rate is 93/100 or 93%.  Before you can adequately address whether or not you should make a change in your protocol, this data is essential. 

Define “Intubation Attempt”.  There is often significant disagreement on what constitutes an “intubation attempt”.  One on hand, some feel that the full passage of the tube through the vocal cords is an attempt.  Others feel that the attempt starts as soon as you stop mechanical ventilations to facilitate laryngoscope placement.  The National Association of EMS Physicians (NAEMSP) debated this issue and came up with a unified position:

“Many EMS services define ‘‘attempt’’ as insertion of the endotracheal tube.  However, anesthesiologists and emergency physicians typically define ‘‘attempt’’ as insertion of the laryngoscope blade.  The ‘‘insertion of blade’’ definition for attempt is preferred because each attempt to enter the oropharynx and visualize the vocal cords potentially results in deprivation of ventilation and oxygenation.  A definition of ‘‘attempt’’ that is limited to tube insertion biases the clinical picture. For example, a patient that underwent four laryngoscopies but no attempts at tube insertion would be inappropriately described as having had ‘‘zero’’ attempts at ETI.  The use of the ‘‘insertion of blade’’ definition also facilitates comparison between prehospital providers and emergency physicians and anesthesiologists, an important analysis that has not been possible to make as a result of the inconsistent definition of ‘‘attempt.’’  Therefore, the definition of ‘‘attempt’’ as ‘‘insertion of laryngoscope blade’’ is recommended.” [ii]

Define "experience".  A difficult discussion.  I must state my bias in this regard.  "Experience" does not mean "seniority" - it must be based on patient care experience or patient encounters.  "Paramedic A" has been working for 10 years and has had 500 patient encounters.  "Paramedic B" has been working for 2 years and has had 1,000 patient encounters, which paramedic has more "experience"?  While "Paramedic A" has more seniority, "Paramedic B" has more experience.  But, patient encounters alone should not be the basis for determining whether a paramedic has enough "experience" to intubate.  You must also evaluate the proficiency rate.  A well-experienced paramedic may still have technique issues that make their success rates less than optimal.

Set standards.  If you are going to keep intubation in your protocol, consider limiting the skill to experienced personnel who maintain a set proficiency rate.  For example, perhaps only "Lead Paramedics" should be authorized to do the high-risk, low frequency skills.  These medics must continually demonstrate proficiency to be eligible for the right to perform those skills.

De-emphasize the merit badge mentality.  Many paramedics may see the modification of intubation authorization as a "step backward".  The fact of the matter is that it is really a step forward.  If we have evidence that a successful procedure really does not benefit the patient (based on scientific research), failed procedure may actually harm the patient and that it is a difficult skill to maintain, the answer is easy.  This is not a step backward, it's actually a step forward!  (Remember MAST suits?).

Finally, remember, it’s about the PATIENT and their outcome.  If we can deliver faster, more effective care, it is our bound duty to make the difficult decision to provide the best possible care for those who rely on our decisions for their very existence. 

There is no room for egos or hurt feelings.