Intubation Is Overrated

One shift I was called out to a code and when I arrived I decided to work it. This was back in the days of the “scoop and run” method of resuscitation so we were trying not to spend much time on scene. When it came time to try and drop a tube, the patient’s anatomy and other factors were working against me. After three attempts, I dropped in a CombiTube and began to ventilate. As I checked placement, I thought, “Huh. This is moving some good air. Let’s roll with it.” I had a firefighter riding with me so I was able to take a moment to do a proper radio report en route, which included the fact that I was unable to intubate the patient and had dropped a Combi. When we arrived, the doctor was ready to pull out the CombiTube and drop an ET tube but noted that air movement was more than adequate so it was left in while they continued to work on the patient.

From then on, I made it a practice to use a CombiTube over an ET tube. Among the reasons for this was that the CombiTube was much quicker and almost always successful without having to manipulate the patient’s neck and jaw in unnatural ways. If I was in a controlled environment, I could drop tubes all day every day but in an ambulance with little room to work, this is usually a different story (and if we are honest with ourselves, this is more often the case than not). Intubation is an art, one that is very easy to mess up for a variety of reasons.

One of the dogmas of EMS is that intubation is an essential skill and without it, there is not much use in being a paramedic. Such dogmatic devotion to skills is largely what has held EMS back as a profession almost from its inception. The reality is, as a group, paramedics stink at intubation. Let’s keep in mind that intubation was never intended to be practiced in the back of a cramped moving vehicle and that the method by which a patient is intubated does not lend itself well to an ambulance. Even medics who are good at intubation often run into difficulty dropping tubes in such conditions.

It’s time to let it go.

There has been a big blow up about intubation possibly being removed from the National Scope of Practice model. I really hate to tell those who are crying foul over this that research does not support their position. As mentioned above, EMS as a group stinks at intubation. Multiple studies have also shown that other methods of airway management (even something as simple as an OPA) can provide the ventilation necessary for out of hospital management of cardiac arrest. In the AHA algorithms, airway management is way down the list in favor of quality CPR and defibrilation.

I’m offended by much in this situation but mainly I’m offended at providers whose egos are so fragile that they feel the need to engage in fear mongering (“this is about saving lives!”!) and threatening to leave the field if they can’t intubation (if that’s how you feel, then please do see yourself to the exit). Paramedics have the audacity to make these claims while engaging in a medical field that has some of the lowest educational and entrance requirements of any branch of medicine. We have the audacity to demand the right(!) to drop tubes, administer medications, and perform procedures with no real education on what these treatments truly mean to a patient.

EMS needs to let go of the hero/victim mentality.

I stand as an advocate for EMS even though I chose to leave the field some time ago. I will fight, I will advocate, I will encourage those who practice paramedicine to be the best they can be. But, I do not stand with my brothers and sisters on this issue, not when we are simply not good at this skill and when there are much more efficient options for airway management which provide quality ventilation. If we truly want to have the means to give our patients the best care that we can possibly provide, we need to check our egos at the door and be willing to allow skills that do not benefit patients to be placed to the side.

Anything short of that, we are not in it for the patients. We are only in it for us.


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