This article and the issues it presents are at the heart of what's wrong with EMS. Airway management has been a crucial component of ALS care for years. It has not been until recently (the last five, or six years), that there have been multiple reports of commonplace issues of missed esophageal intubations nor of extensive "complications" of ETI. What has gone wrong? Where have all the skills gone? Where has clinical compentency gone?

  If there are existing issues in an EMS system with ETI, why are those issues not dealt with through a QA (CQI/QI/TQM, or Six Sigma) program? Too busy deciphering the acronym of the week perhaps? By applying the concept that we are"duty bound" to provide the care that would be the "fastest" and have higher efficacy, would not all patients recieve code three and/or helicopter transportation to the ED?

  Out of curiosity, how are we supposed to know if there are secertions or vomitus occluding a glottic opening? Without automatically presuctioning everybody I'm going to intubate, I can't think of a way. And we all know that there's rarely stuff there, right? So right off the bat we're at a supposed 50% on many our attempts. An ED doc might be able to get that tube one the 1st time, but that's an airway we've been working on. I personally can't place a combitube in ten seconds, so that's out too. What if there's stuff I can't see when placing the combitube? Now we just blew it into the lungs when ventilating through that. There goes that save via a pneumonia in the ICU.

  And also out of curiosity, what do we do if we do get a code save and the patient wakes up, or becomes anything but a GCS of 3? MFC (Medication Faciliatated Combitube)??? Or do we now drop them with drugs and take the combitube out and attempt to place an ETI? These are the folks that are in the most need of quality respiratory support, preferably via a vent. Didn't we take the EOA/EGTA out a while ago for a reason?

  This is a local medical oversight issue, not one in which the AHA should be weighing in on. If there is a problem in a particular system, it needs to be addressed, and the CQI process needs to remediate, and/or arrange the necessary opportunities for skill maintanence. If a paramedic training program can get time for it's students in an OR, why not offer that time as a source of CME?

   Lastly, this is the opening salvo in the total loss of ETI for the field. Cardiac arrests are the most frequently intubated group of patients intubated by paramedics. Where is our skill level going to go with the loss of anywhere from 35-65% of our intubations?

Ronnie F. Loyd, EMT-SF