EMS DOCS’ PERSPEC TIVES ON STREE T MEDICINE
Blind insertion or blindly inserted?
By Neal J. Richmond, MD, FACEP
One thing we do in EMS that many of us most pride ourselves on is advanced air- way management—though gaining that
pride may have required a few moments of pants-wetting terror along the way.
For patients in respiratory failure rapidly
progressing to respiratory or cardiac arrest,
there are few scenarios that run us right up
against the front lines of life and death, and
with so much potential to affect the outcome.
These cases bring into focus the cognitive (knowledge), psychomotor (manual), and
affective (emotional/psychological) elements
of our job like nothing else we do. Yet evidence
keeps piling up about how much of a mess we
often find ourselves in while managing them.
SKILL BURN-IN & MAINTENANCE
Initial skill “burn-in,” for one, is inadequate. Only
five live intubations are required for national certification. For perspective, emergency medicine
residents and nurse anesthetists need at least 35
and 200 tubes, respectively, for certification and,
in both cases, these are placed in the controlled
and supervised environment of an ED or operating room.
1 A 1998 study demonstrated that
anesthesiology residents must place more than
50 tubes under direct supervision before they
can achieve a success rate of 90%.
Somehow, though, after those first five tubes
and several years’ fewer training, paramedics
are miraculously supposed to hit the mark on
their knees, in dark rooms, intubating morbidly
obese patients with full stomachs and upper
GI bleeds, surrounded by upset family members, barking dogs and screaming children.
We also get a C-minus grade for skills maintenance. There are exactly zero requirements for
demonstrating intubation or other advanced airway proficiency for national recertification, and
with the increased number of advanced-level
practitioners providing our communities with
a “higher” level of care, we’re effectively diluting
the advanced skills of practitioners by increasing the number of providers performing them.
A 2003 study of prehospital advanced level
airway interventions in Pennsylvania showed
that almost 40% of personnel performed no
intubations in the space of a year, and more
than two-thirds had placed two or fewer tubes.
Which of these thousands of EMS personnel
would you want to show up at your mom’s house
when she’s in pulmonary edema?
We also have little to go on in terms of objective verification of tube placement. Some studies have demonstrated not only a significant
rate of misplaced endotracheal tubes but, even
worse, that these go unrecognized in almost
25% of cases—the highest rates occurring in the
absence of continuous end-tidal carbon dioxide
(EtCO2) monitoring capability.
A BLIND SOLUTION
Armed with this knowledge and the more recent
understanding that endotracheal intubation
leads to increased pauses and decreased time-on-the-chest in cardiac arrest, we did what we often
do in EMS: We closed our eyes, threw a solution
at the problem, and hoped for the best. In this
case, we adopted the widespread use of blind
insertion supraglottic airway (SGA) devices.
Problem solved, case closed. Unfortunately,
though, no one checked to see what happens
with these devices in real cases of respiratory
failure and cardiac arrest.
A recent study looked at more than 300 consecutive King SGA placements, comparing subjective success recorded on the patient care report
(PCR), with objective verification of tube placement on the uploaded capnography waveform.
They found that tubes had been misplaced in
almost 20% of cases, and that more than 14%
went unrecognized, reflecting a situation not
much different from what we already knew about
By the way, this doesn’t mean there’s anything
wrong with either the tube or the person putting one in. What it does mean is that we probably shouldn’t be placing them in the absence
of EtCO2 monitoring capability. It also means
that we must have the necessary quality assurance processes in place, as well as the software,
personnel, and buy-in to ensure that EtCO2 isn’t
only being used, but that it’s being used correctly.
Once again, we find ourselves taking a fresh look
inside the “box,” including a recently proposed
name change from EMS to Paramedicine, and
the development of a white paper charting a
new course for EMS by 2050.
What if we took just one thing, though, and
set our sights on accomplishing it before the next
name change or white paper? What if we set a
requirement for continuous EtCO2 monitoring
capability, as well as transparent, accountable
QA processes to go with it? How many lives
would we save? How much respect would we
gain? How proud would we feel to get it right
every time? JEMS
1. Accreditation Council for Graduate Medical Education. (2017.)
Emergency medicine defined key index procedure minimums: Review committee for emergency medicine. ACGME.
Retrieved Jan. 2, 2018, from www.acgme.org/Portals/0/
2. Konrad C, Schüpfer G, Wietlisbach M, et al. Learning manual skills in
anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg. 1998;86( 3):635–639.
3. Wang HE, Kupas DF, Hostler D, et al. Procedural experience with
out-of-hospital endotracheal administration. Crit Care Med.
2005; 33( 8):1718–1721.
4. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in
an urban emergency medical services system. Ann Emerg Med.
2002; 37( 1): 32–37.
5. Silvestri S,Ralls GA,Krauss B, etal.Theeffectivenessofout-of-hospital
use of continuous end-tidal carbon dioxide monitoring on the rate
of unrecognized misplaced intubation within a regional emergency
medical services system. Ann Emerg Med.2005; 45( 5):497–503
6. Vithalani VD, Vlk S, et al. Unrecognized failed air way management
using a supraglottic airway device. Resuscitation. 2017;119: 1–4.
Neal J. Richmond, MD, FACEP, is board cer-
tified in emergency medicine and medical
director for the MedStar Mobile Healthcare
System in Fort Worth, Texas.