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Handovers,
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Critique w/ Cliff Getting Nerdy: Reaching the Top of
Reid a bLoG oN bLOgs Intermolecular Force the Pyramid
August 16, 2019 August 10, 2019 August 7, 2019 August 2, 2019

Airway Management
Supraglottic airways are superior and intubation is for doctors…
April 10, 2018 | Guest Post Michael Perlmutter
 If you despise me and everything I stand for by the end of this post, it’s ok. You may not agree with every point
I make in this post. Suffice it to say that this is controversial. Nonetheless, I think we need to leave our egos at
the door and have a meaningful conversation about what’s best for our patients. Despite decades of practice
and not a small amount of bravado involved with intubation, we should be appraising the evidence with a
critical eye and asking ourselves whether intubation by paramedics in the field is in the best interest of the
patient. When it comes to airway management, we need look ourselves square in the eye and ask, “are my
intentions honourable?”

Endotracheal intubation has been a core paramedic skill since the inception of the profession. To this day, it
remains a highly coveted skill by paramedics. We take great pride in the fact that we are granted the privilege to
perform this invasive and difficult procedure. In paramedic school, intubation receives the lion’s share of
attention within the broader umbrella of training related to airway management. In most programs, some time
and attention is given to basic techniques such as face mask ventilation (FMV) with a bag-valve-mask (BVM)
and adjuncts such as oro- and nasopharyngeal airways (OPA/NPA), and supraglottic airway devices like the
CombiTube, King LTD, and LMA-type devices. However, the most time and attention is almost always given to
intubation. In some sense, there is sound logic to this model: intubation is in many ways the most technically
difficult of these skills to master, and since intubation often involves the use of neuromuscular blocking agents,
it is important to ensure that an endotracheal tube can be placed after spontaneous respiration has ceased.

Unfortunately, the time spent on intubation in paramedic school (even if it does comprise the
majority of didactic time devoted to airway management) falls far short of what should be
considered standard for a provider attempting intubation. This is even more true for paramedics
performing medication-assisted airway management (MAAM). Within the paramedic course itself, there is
often minimal time or attention given to human anatomy; this issue is compounded by the fact that few
paramedic students have completed a rigorous course in gross anatomy prior to beginning their EMS
education. Furthermore, the physiology and pathophysiology related to anesthesia are rarely addressed in great
detail, which leaves paramedics ill-prepared to anticipate and mitigate the potential risks and benefits
associated with prehospital RSI. The emphasis on intubation in the context of limited education and training
time means that FMV and SGAs--often considered inferior “rescue” techniques for cases of failed intubation--
are given insufficient time and attention.
 Historically, a core component of airway-related training in paramedic school has been time in the operating
room (OR) under the tutelage of an anesthesiologist and/or certified registered nurse anesthetist (CRNA).
Students were required to perform intubation on live patients; most programs required between 5 and 10
successful intubations. This OR time is a much-anticipated highlight of most paramedic programs, and time
spent under the supervision of an airway specialist was invaluable. That said, the idea that a provider (any
provider) is competent to manage an airway, much less competent at laryngoscopy, after 10 intubations is
laughably absurd. Most emergency medicine residency training programs require a minimum of 50 intubations
carried out under heavy clinical supervision and subject to intense review to graduate. Residents in anesthesia
programs perform at least 500 intubations in the course of their training. In recent years, numerous paramedic
programs have cut OR time completely from the curriculum. As a result, students no longer have the ability to
perform their first intubations on human patients under the direct supervision of experts. Clearly, 10
intubations in live patients is hardly sufficient to achieve competence, but it is arguable that the benefit
conveyed some benefit nonetheless. In the current era, this has been replaced with practice on mannequins and
(if fortunate) in a cadaver lab. Anyone with experience managing airways will know that these training
modalities are not equivalent. These issues inherent in paramedic education are compounded by the lack of
appropriate education and training for paramedics during their orientation and training period following
employment. Even in systems that do have processes in place to assure competence, one must ask if this is
sufficient. Studies have shown that for the average paramedic working in a dual-medic system to achieve 100
intubations (100 instances of performing a procedure is frequently cited as a minimum number to achieve
competence), that paramedic would need to be presented with 200-250 opportunities to intubate per year, for
five years. With the possible exception of a few systems, this is simply not a realistic scenario.
With this discussion of the tremendous differences in training to establish baseline competence for paramedics
compared to physicians in mind, we should consider the question of what alternative paradigm exists. We know
that pathology does not respect geography: the patient who requires airway management 50 miles from the
hospital requires that airway as surely as the same patient in the resuscitation bay at the trauma center.
Therefore, some method of airway management must be available in the field. In recent years, tremendous
advances have been made in the design of supraglottic airways. In particular, the i-gel has been developed from
the classic laryngeal mask airway (LMA) design. The i-gel is placed blindly, and without the need to inflate a
balloon cuff. Instead, this device makes use of a thermoplastic polymer that uses body heat to allow the mask
gel to conform to airway anatomy, thereby isolating the tracheal opening and facilitating mechanical
ventilation. Many LMA designs have been updated to make placement easier, and to facilitate eventual
intubation through the device.

Even prior to these advancements, Darren Braude and his group in New Mexico were making use of SGAs for
initial airway management in the prehospital arena. Instead of attempting to place an endotracheal tube for
patients requiring advanced airway management by EMS, Braude’s group made use of supraglottic airways to
achieve airway control. This was done in the setting of helicopter EMS (HEMS), with arguably the sickest group
of patients that EMS can be called upon to treat. SGAs were also used in the context of MAAM--these were not
SGAs placed in patients in cardiac arrest. Their data is compelling: compared to endotracheal intubation, the
incidence of successful placement on first attempt is higher and the rate of global complications is no higher.
Other systems have been similarly successful. Further strengthening the argument for SGAs in place of
endotracheal tubes is the reality that numerous studies have demonstrated that prehospital intubation is
associated with decreased rates of successful resuscitation in the setting of out-of-hospital cardiac arrest. Not
only that, but in a manner similar to airway management in patients not in cardiac arrest, the incidence of first
pass success using SGAs is higher than that of endotracheal intubation in patients who are in cardiac arrest.

Having laid out a range of issues associated with paramedic-performed intubation, is it time to transition to an
airway management paradigm in which endotracheal intubation is no more? It depends. In this, as in so many
things, the aphorism that, “if you’ve seen one EMS system, you’ve seen one EMS system” holds true. Paramedic
HEMS systems in Australasia and the United States have demonstrated that paramedics can provide
prehospital intubation safely and effectively. HEMS paramedics in Victoria have long been a shining standard
of what intubation performed by paramedics can be. Their success and complications rate equal or exceed that
of physicians performing the same skill in the same environments. Similarly, led by Dr. Jeff Jarvis (a paramedic
himself), paramedics in Williamson County, Texas are performing prehospital intubation using a system of
Delayed Sequence Intubation (DSI) combined with video laryngoscopy and are achieving outstanding results. It
is clear that paramedics can perform prehospital intubation safely and effectively. So if these systems are doing
it, why is it not the norm?

What is lacking in many systems is the rigorous initial and ongoing training, quality assurance and
improvement (QA/QI), and close medical director oversight that characterizes the systems mentioned here. In
those systems, paramedics are taught to a level appropriate to the substantial risk inherent to the procedure,
and are tested on a regular basis to ensure ongoing competence. There is use of cognitive aids such as call-and-
response checklists, a team-based approach with roles clearly defined, and attention paid to the significant
human factors at play when the decision is made to undertake intubation in the field. Of critical importance, all
cases are critically reviewed, with an eye to opportunities for future improvement. There is a commitment to
investment in education, training, and equipment necessary to perform prehospital intubation safely.

So, if your system has processes in place for detailed education and training regarding
anatomy, physiology and pathophysiology, rigorous QA/QI processes, and strong medical
director oversight, your program might be right to begin or continue the practice of
prehospital intubation by paramedics. Unfortunately, it seems there is a relative shortage of systems
that meet this description. For these systems, SGAs may be a superior alternative. With first-pass success rates
of 90% or higher and data demonstrating no increase in complications when compared to intubation, patients
may be better served by a supraglottic airway device as the advanced airway of choice. In the opening, I noted
that intubation by paramedics remains a highly coveted skill, and that most paramedics take pride in the
privilege we are granted to perform it. In the interest of full disclosure, it should be noted that I fall squarely
into this category: I continue to intubate, and I do it well. But I must admit that these days I am not so sure that
I should continue to do so. Are you?

Disclosure: I have no financial conflicts of interest to disclose. Unfortunately, there is a dearth of wealthy
individuals and corporations willing to pay a paramedic-turned-medical student exorbitant sums for my
opinions and/or endorsements.

Michael Perlmutter has worked in EMS for the last ten years. He has been an EMT in Southern California, and a paramedic in a busy
911 system in the Twin Cities of Minnesota. He also worked as a flight paramedic for three years before hanging up his wings to begin
medical school at the University of Minnesota Medical School in Minneapolis, MN. He is interested in Emergency Medicine, EMS
Medicine, and Critical Care. His research interests include advanced airway management, sepsis care, and the many uses of ketamine.
He is an avid consumer and contributor to the Free Open Access Medical Education (#FOAMed) movement. He observes, comments,
and contributes via his Twitter handle @DitchDoc14.

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10 comments
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Mediocrity has become the norm. Push providers through with minimal training and poor instructors. Allow the
weakest link to set your protocols. Now for the real issues. All I hear about is the poor performance of paramedics,
Train them the right way, ventilate prior to intubation teach the right way not some abbreviated nonsense. Bad
days happen but if your having a bad day more than once or twice a year you need practice. Being aware of your
own poor practice is the first step in correcting a problem. Don’t make excuses, take pride in your practice. Make
an effort to be better than everyone else.

George Bevilacqua · a month ago · Reply

Bravo! My hero was Joanna Cassidy from the 80’s TV show 240 Robert. She flew the freakin police helicopter.
Very forward thinking for 1979. Her character’s picture is on my locker as a reminder.
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weight loss · 3 months ago · Reply

Amazing talk on RV dysfunction.

Sean Duchemin · 3 months ago · Reply

Question: What formula did you use to plot the serum concentrations over time with cumulative dosing?
Thanks!
Mike Pietersen · 4 months ago · Reply

Ok, nervous newly transplanted Atlanta paramedic here about to face southern summer head on. What do you
recommend to prevent this complete catastrophe? Worth getting an insulated lunch bag or something to store them
throughout the day? Or do you think generally as long as it is not in direct sunlight, it will survive the ambient
swelter?
Natalie Zink · 4 months ago · Reply

There is no such thing as too sick to transfer. As you mentioned, the patient would have died if you left him.
Absolutely would have taken him and given him the best chance at survival. Strong work.
Andrew · 4 months ago · Reply

Great references to The Other Guys. Another great article from FOAMfrat. Thanks

Tim Redding · 4 months ago · Reply

This is really helpful to me as a medic student just into pharma. Love the 5 half-lives rule (and that 8 is just
39 in disguise!). This is great information presented in a way I can understand, and I'll be interested in seeing how
they do it in the ICU. Hopefully better than the pharmacist explained! Had a 39 yo pt the other day w/ a BP of 50
and watched them give him every pressor possible to try to get it up, which makes it real. Thank you for the time
you put into this and for sharing it.
trainerjims · 4 months ago · Reply

I couldn't find the link to the course.

Mike · 5 months ago · Reply

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