Debating Intubating

Aug 26, 2014

As if the debates about arming EMS personnel and merging fire and EMS weren’t enough, I decided to take a stab at sharing my thoughts on another controversial one this week.  Of all of the skills and medications that a paramedic possesses in their toolbox, there is none that they are more protective of than intubation.  There is an almost constant debate not only in the EMS community but the medical community as well as to whether or not paramedics are good enough at intubation to be proficient at the skill, and do they use it enough to make it worthwhile for them to keep it?  Last week, Sean Eddy had a great take on this over at Medic Madness, and I thought that I would add my two cents to the discussion.

As our field has evolved, we are intubating people less and less every year.  I like to say that intubation has gone from a life saving procedure to a life sustaining one.  More times than not, on the rare occasions where I intubate non-cardiac arrest patients I find myself doing so to protect their existing airway rather than to improve their oxygenation.  CPAP has changed the archaic treatment of CHF patients particularly that used to result in paramedics high fiving each other in the parking lot of the ER as their field intubated patients struggled to ween themselves off of ICU ventilators.  We used to think that nitroglycerin, morphine, and lasix with some PRN orders for versed was the way to go.  It’s not!  Who knew?

There have been studies done over the last fifteen years, many of them recommending the cessation of field intubations after having retrospectively looked at success rates particularly among those incidents where a patient was turned over to the ER with an esophageal intubation, or as one resident in my current system likes to refer to it, they “stuck the tube in the goose.”  While I realize that studies like these take time to complete, maybe they are looking at the wrong things.

A better take on the intubation debate would be to look at not only overall success rates but how quickly missed intubations are recognized, and what actions are taken after they are recognized.  I feel that paramedics are good at intubation but with all of the moving that takes place with patients in a transported cardiac arrest, and all of the potential for head and neck manipulation during patient movement, the greater issue is missed tubal migrations.  Monitoring end tidal CO2 is a great way to quickly recognize and correct these incidents.

Waveform capnography and numeric capnometry need to be used on every single intubated patient, every time for the duration of the patient’s time with EMS.  There is no better way that I have found to confirm a tube not only initially but also to continue monitoring that it is in the right place for the entire patient contact.  Commonly considered a “secondary” means of confirmation, I would almost upgrade it to primary with regards to having a patient intubated, and “downgrade” auscultation to a means of making sure the tube depth is correct and breath sounds are clear and equal bilaterally.  Furthermore, when a patient comes up with low or no capnography reading, especially in a patient that is alive, we need to not treat it as an equipment failure because our ears might tell us something else.  Instead, we need to rely on the information the machine is giving us.  This is one instance where we have to treat the monitor and not the patient.

I once had a patient who was successfully intubated with a tracked, trended capnography for the entire time that we had him.  After the patient transfer to the hospital bed and before he had been removed from our equipment, the “apnea” alarm on our monitor started going off.  I was approached by the doctor after they had called the code, and he told me that the tube was in the esophagus the entire time.  Not so fast, sir.  Thankfully, our medical director was present in the ER and we were able to review the trending capnography with the uniformed doctor who was quickly corrected.

There are a lot of things that an intubator can do to make their role in a call more effective.  Here are a few tips to help make sure that patients not only get their airways managed, but they stay managed:

1.  Use capnography on every single intubated patient – I think we have covered this one thoroughly.  Trending capnography is your friend and if there is any debate, it is one of the few things that can save your job and your career.

2.  “Bomb proof” your patient after intubation – If you are going to transport your patient, do everything that you can to make sure that head does not move.  The easiest way to do that is to slap a collar on the patient.   This will limit a lot of anterior to posterior and lateral movement that your patient would otherwise experience while being extricated and transported.  If your patient is too big to fit a collar on, consider putting them on a backboard for transportation and secure their head with headblocks to keep it where you want it to be.

3.  Confirm and reconfirm – When your patient is first intubated, make sure you note where that tube is at the lip line, and get a baseline set of lung sounds on the patient.  After the patient is rolled to put them on whatever device you want to extricate them with, listen to lung sounds.  After that horrifically bumpy road that you go down on the way to the hospital, listen to lung sounds.  Before you transfer care to the ER, listen to lung sounds.  As I said, capnography should be the gold standard for confirmation of intubation, but reassessment of lung sounds can tell you a lot about what is going on with that tube can help prevent a problem before it happens if you start to note a change in depth of the tube or a change in the quality of the patient’s lung sounds.  Think of capnography as the “check yes or no” boxes and lung sounds as a way assess the quality and effectiveness of a tube.

4.  Be a humble intubator – If you are not sure if the tube is in, say something.  If you cannot see the chords, say something.  Use the tools that you have in your toolbox like a boujee and crich pressure.  Don’t be afraid to elevate the patient’s head to give yourself a better field of vision.  One medic that I know likes to verbalize everything when she intubates much like she did in paramedic class, “I’m sweeping the tongue, I see the epiglottis, I see the chords, I am passing the tube.”  It helps her keep everything straight and insures that she does not miss a step.  Most importantly though, if you don’t think you can get the tube, let somebody else have a shot, or grab a backup device like a combitube or KING airway.

5.  Practice makes perfect – Finally, most paramedics do not practice nearly as much as they should with intubation.  It is one of those high liability, high skill level, low frequency skills.  Last year, I intubated eleven patients.  It was most that I had done in quite some time.  Still though, that is less than one patient per month.  Make time to practice and take advantage of anything that your employer might offer to you to help you become a better intubator.

If you ask me, I think that studies on the quality of prehospital intubation need to revisit the topic.  The medical world has given us better tools to not only make sure a patient gets intubated, but also make sure that they stay intubated.  Many of the studies that have come out over the last ten years have not done as good a job as they possible could with figuring this into the equation.  Also let’s create some national standardized metrics for intubation and let’s better define for example what an attempt means.  Is it when we pass a blade and visualize?  Is it when we attempt to pass a tube?  Every system says something different.  Standardized metrics followed up with consistent documentation is the only way to know how good we really are.

The bottom line is for now intubation is still in the paramedic toolbox is almost every system out there.  It is used in different ways in different places but it is there.  From my personal experience I don’t see a need for it to go anywhere however I feel that there are a lot of things that we can do to make ourselves better intubators.  Take the time to study, practice, and be the best intubator that you can be!