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December 2, 2009

San Francisco EMS conference features airway management debate

By Shannon Eliot
EMS1 Associate Editor

SAN FRANCISCO — The effectiveness of endotracheal intubation was questioned during a guest presentation at an EMS conference in San Francisco.

Dr. Henry Wang, Associate Professor and Vice Chair for Research of the University of Alabama at Birmingham Department of Emergency Medicine, presented data showing that the procedure does not improve patient survival or neurological outcome, and in some cases may actually worsen survival.

He delivered the message during his presentation on prehospital airway management and the KISS principle at the "ABCs of Emergency Medicine,” which was held by the San Francisco Paramedic Association in September.

Considered the gold standard in airway care, endotracheal intubation is believed to provide direct channel to the lungs, improve ventilation, and prevent aspiration, according to Wang.

However, the live-saving intervention might actually be killing people, he said.

"Data show us that patients who are intubated by paramedics have a four times greater chance of dying than those intubated by the emergency department," Wang said. "The odds are twice as high for a poor neurological outcome. It's essential to look deeper as to why this is happening, because in some situations this measure of care appears to do more harm than good."

One in 4.5 patients is exposed to an endotracheal intubation error, said Wang. Further, studies have shown the average time to place the tube is 45 seconds, which is 3-4 times greater than the ideal of 10-15 seconds.

Wang acknowledged the difficulty of the procedure, but also noted the disparity in training standards for first responders.

"There is no such thing as an easy prehospital airway," Wang said. "It's challenging to do a complicated procedure in a chaotic, uncontrolled environment on a severely ill patient in unergonomic positions. This is precisely why paramedics need the best possible intubation skills."

While emergency residents need to successfully place 35 endotracheal tubes before graduating, paramedics need only five, said Wang.

"The magic number of 15-20 ETI placements seems to be the point at which providers start feeling comfortable," said Wang. "This baseline — which focuses on comparatively stable, easy patients — is far above the minimum number of five that we’ve artificially constructed."

Wang also acknowledged the challenges of obtaining proper training for health care personnel, as legal concerns and competition for time and space provide barriers to development.

"Securing OR time for intubations is the single most difficult aspect of my job as program director," said Wang. "We are also seeing some ORs completely shut out paramedic students in favor of medical students, which also makes it difficult for those learning to refine their skills."

While endotracheal intubations present many ongoing challenges, Wang encouraged audience members to not give up and not stop intubating.

"One message is to simply be aware that bad things can happen," Wang said. "If you can't intubate like a pro, know your limitations. A botched airway can sometimes be worse than if no tube was put in at all."

Wang also mentioned that ETIs are not the only method in airway management.

"Endotracheal intubation is only one option, and sometimes there are better options," Wang said. "Alternate airways can provide solutions. Just remember to keep it simple."

Art Hsieh, SFPA Chief Executive Officer and Director of Education, hopes that such controversy and discussion will institute a positive change.

"Some attendees were surprised with the data and upset with the idea that ETIs could do harm," Hsieh said. "But if such presentations continue to push us to improve and reject the status quo, then they end up being highly successful."

The conference, attended by more than 150 EMS professionals and students, focused on an interdisciplinary approach to emergency medical education.

"The goal of the conference was to advocate through education," Hsieh said. "It is often difficult to leave the region to get high-level information from experts in the field. By featuring a wide range of emergency care experts — including not only paramedics, but also physicians, nurses, and researchers — we were able to generate quality discussion and a unique educational opportunity."