My paramedic program required 10 live intubations in the OR. I did my first 9 with such ease that the anesthesiologist was recruiting me to join his practice. I then missed on my next 3 attempts all within 20 minutes of each other.
I got my first field intubation in 1993 during my ride time. It went in easy and caused me to do a funky moon walk break dance afterwards in the ED parking lot. I got a second ET while riding with another medic, but couldn’t get the job done on my only ET attempt while precepting. My first chance to intubate on my own, I missed and ended up having to use the bag valve mask all the way to the hospital where I delivered a very dead patient with a lot of air from difficult bag valve ventilation in her belly. Over the years I racked up well over 200 intubations, but as I have mentioned previously, I did not always get them on my first attempt. This I can say: the more I intubated the better I became. I attribute that to experience and a willingness to attend every airway class I could. Where my preceptor had to take over for me when I couldn’t get the tube, as a preceptor, I have on many occasions, had to step in and get the tube when my preceptees could not despite allowing the preceptees two tries.
Over the years I have been witness to and also heard many accounts of pass the larenygyscope codes, observed significant delays in compressions while ET was attempted and, while I have never done it, I have heard of and witnessed medics bringing into the ED patients with ETs in the belly (I have even seen this after the implementation of waveform capnography, although it is a much rarer occurance).
When I started we didn’t have supraglottic airways. We didn’t have backup airways. We didn’t have rescue airways. It was ET or bag. I believe if, when the world was young, there were King LTs, Combitubes and LMAs, the gods who created us, might never have given us the ET tube.
Does this mean I think paramedics should no longer be allowed to intubate? No, but I do think medics have to be retrained in how to think about airway management and to approach each airway encounter with an open mind to what will will be best way to ventilate a patient and pose the least risk to the patient.
Lately, in my job as a clinical coordinator, I have had a unique opportunity to sit in on regular SIM Lab airway sessions taught by two outstanding airway physicians and have really had my mind expanded into both the proper thinking and preparation that should go into each airway encounter. Three thoughts I have learned should always be in a paramedic’s mind when approaching an airway: 1) What is the best airway for this patient? 2) How can I maximize my chances for success on the first pass? and 3) What are my backup and my rescue plans should things not go the way I want?
I do believe there are situations where an ET tube is a critical option for the patient and it would be a shame not to have it available. But if it is available, paramedics have to have the training, equipment and medical oversight necessary to see that their patients get the best airway care possible. The days of handing a larengyscope to a new paramedic and telling him to go out and not kill anyone need to come to an end.
Kelly Grayson, aka Ambulance Driver, mentioned one of his previous column’s in a comment to this post. Read The Airway Continuum in which he writes about what it takes to accomplish the necessary airway training. Excellent article.
Our annual airway training, which we are now instituting, for the RSI medics we sponsor includes a 4 hour diadactic class in airway management with review of all the services’s RSI attempts from the previous year, a 3 hour SIM Lab airway session, minimum 6 tubes per year(if you can’t document field tubes, the medic can go to the OR or SIM Lab to fill in the rest), and passage of an annual exam. Medics also have to participate in an annual skill session that includes intubation and surgical airway using pig tracheas.
I would like to see all services, RSI or not, be required to have an annual 4 hour airway session, annual skill sessions, and annual tube minimum that can be filled out with mannequin intubations if the number of field tubes are not reached.
The key to it all, I think is the class with an emphasis on ventilation not intubation. By all means read Kelly’s article.