Some Thoughts on Intubation

Sometimes I wonder if the debate about whether or not paramedics can and should intubate will never end.  I am happy to say though that I have successfully intubated six out of seven people since I started at my new service back in December.  They were all cardiac arrests.  Not a single one of them had a pulse at the time that I tubed them.

Coincidentally, with the tools I have at my disposal, I have yet to have a patient that I have said, “Boy I really think I should intubate this person right here and right now.”  I have, on the other hand said “this person might by a tube once we get to the hospital if what I am doing doesn’t start working soon.”

Every one of us has worked with an airway “guru” at some point during our career.  You know who I am talking about: that person who can tube anywhere at any time by any means necessary.  Right side up, upside down, nasally, digitally.  You name it, they have done it.  I, sadly, am not that person.  In my twelve years at a paramedic, I would best describe my ability to intubate patients as “satisfactory.”  I can get the job done.  I know enough about anatomy that I can find my way around a patient’s airway and get that tube.  I could certainly be better though.

Personally, in twelve years, I can say that I can count on one hand the number of living patients that I have myself intubated.  For me, it is a practice that I have always been more conservative with.  In my old system, we were 10 minutes or less from a hospital from just about every place in my coverage area, so it was always a risk vs. benefit of the time it took to get a successful tube on the patient.  The call had to be made for the meds.  The meds had to be drawn up and then administered, and then the tube had to be passed.  In the time that all of this was taking place, the patient was being ventilated, good or bad, and time was ticking away most often on scene with both my partner and I in the back of the truck waiting for another unit that might or might not be coming to drive us to the hospital.

One thing was apparent to me though.  The technique I had to use when intubating a live patient was completely different from intubating a cardiac arrest patient.  Without the use of paralytics, I found myself having to occasionally shoot through a set of moving vocal chords and get my timing just right.  After that person was intubated, the focus of course turned to sedation and keeping that freshly intubated patient comfortable.

I wonder sometimes if Rapid Sequence Intubation has its place in prehospital care especially as other treatment modalities evolve.  I do not feel my experiences with intubating patients is that unusual for a modern day paramedic.  With CPAP we are not intubating as many asthma and CHF patients.  With the adjustment to ACLS protocols we are not intubating cardiac arrests until a later stage in our codes and when we tube patients the majority of them are already dead.

The technique and skills that we use to intubate a dead patient is completely different from the ones we use to intubate a live one.  Dead people don’t desat, and the time to play and look around for those chords becomes a bit longer.  With living patients there is a lot more to monitor: you need to make sure the medication doses are appropriate to keep a patient sedated.  You need to watch their heart rate because of vagal stimulation, their O2 saturation level to make sure that that “tank” is full of oxygen.

While many are very good at monitoring all of this and “getting the job done” we far too often judge our ability to intubate based solely on the number of intubations we have done, live or dead and that is the wrong way to evaluate ability.

I don’t think prehospital RSI is a completely inappropriate tool for a paramedic to have in their tool kit, and I have seen its benefit throughout my career, but at the same time, I do not feel that we, as prehospital providers, are completely prepared for all that its processes entail.  There is a lot to think about far beyond the act of passing a blade, visualizing chords, and introducing an ET tube.  It needs to be a well orchestrated methodical process that must be rehearsed and reused for a person to be proficient in it.

Are paramedics good at intubating?  Absolutely, however we are not good for the reasons one might think.  The true measure of a paramedic’s ability to intubate is derived from the challenges that they face.  It’s not the fact that they intubated an anterior “Grade 3” airway.  It’s the fact that they did it in a dimly lit room with minimal help while lying flat on their stomach in a 4th story walkup.

While recreating these situations to evaluate them might not exactly be easy, more needs to be done to prepare paramedics for the challenges that they will face, especially with the live patient that requires intubation, and where better to do that than where they are alive a majority of the time: in the operating room.

When I went through my paramedic time, there was no place in the hospital that I dreaded more than the OR.  It was terrible and I was terrified, but I did learn a lot.  I got better at bagging patients and better at intubating because I had the opportunity to learn the patience needed to make sure a patient was adequately oxygenated and remained so while I went in and passed that tube.  I had someone looking over my shoulder to tell me how my technique was and how to improve it.

So maybe that is the answer, more education.  More critiquing.  More practice with the living and not just the dead.  RSI has its place in the field, we just need to do a better job of making sure that we are prepared to do it.

  • DoctorGoodleg

    Scott:

    I think the biggest thing that we need to do in ALS is not make intubation a black or white, all or nothing proposition. There’s a lot of factors that will influence success or lack thereof in advanced airway management.

    I consider myself one of those airway “geeks” (not a guru…yet). I work a busy unit where I see a decent amount of opportunities for airway management, I have taken the courses, read the books, and listened to just about anyone out there with an idea concerning the issue. I don’t have my autographed Dr. Levitan poster yet, but I’m working on it. With that, here’s my thoughts:

    1. Airway management does NOT equal ETI. Positioning, use of basic adjuncts, use of suction, non-invasive ventilation, etc. all send you to the same goal: a patient with a clear airway who can oxygenate and perfuse. I’m amazed at how many paramedic students discount this. It’s a continuum. Not just one thing.

    2. If we as pre-hospital practicioners want to keep ETI in that continuum, we need to step up individually as well as demand our services give us appropriate tools. YOU need to make sure you are proficient with YOUR skills. If you haven’t done something in a while, pull out the manikin! If your service or medical director isn’t mandating (or supplying) waveform EtCO2, proper medication protocols, training and the things we need in the field to perform ETI/RSI with a high level of proficiency, you’re gonna have problems. There is absolutely NO reason for some of the success rates we read in the literature, which is used by opponents to say that paramedics cannot intubate.

    3. Airway management means remembering the goal, and sometimes swallowing the ego. Sometimes you will have to place that supraglottic device, or maybe you have to decide that discretion is the better part of valor and NOT go for it on that patient until you have more resources, be that a flight crew/retrieval team, ED staff or anesthesia. That also means in CPR, if you’re not intubating WITH CPR in progress, then you shouldn’t be doing it! Drop the supraglottic and go from there. Personally, I think that we can intubate with CPR, I’ve tried using inline stabilization with a manikin and it seems to work well.

    Anyway, sorry for the long winded reply, but as I said, this is close to my heart.

    Remember what you’re doing is supposed to be for the best interest of your patient…not your stats.