Paramedics: A Danger to Patients?

By Michael West, George Washington University

There’s a motto in emergency medical services (EMS) that one learns during his first days of training, “no airway, no patient.” Paramedics are trained in advanced pre-hospital medicine including advanced airway management techniques. One of the most notorious of these techniques is the endotracheal intubation (ETI), a technique in which the paramedic inserts a tube down a patient’s throat in order to use it as an airway adjunct. The use of ETIs “in field” (outside of hospitals) has come under heavy criticism given the less than stellar statistics its use has produced. Many argue that paramedics performing ETIs actually harm the patient, while others support the idea that paramedic ETIs save numerous patients who would have otherwise died (JEMS 2). The debate is of course justified; patients deserve the best treatment possible with the least risk associated with it.

Leave it to the Doctors

Mounting data seems to support the removal of ETI privileges from paramedics. Multiple studies conducted in both public and private EMS systems concluded that paramedic ETIs have no effect on patient survival rates (Gausche et al. 1). Shockingly, in a study conducted by Dr. Henry Wang, the use of an ETI actually increased the risk of death and led to negative neurological outcomes (Wang 1). In a survey of studies conducted by Wang, he concluded that nearly 1 in 5 patients has been exposed to an error in tube placement, ranging from incomplete insertion of tubes to esophageal damage as a result of forcing the tube in (Wang “Paramedic”). Critics also point out that paramedics will often neglect other treatments in order to perform an ETI. Just one example of this is the interruption of chest compressions during CPR. In a study published in the Annals of Emergency Medicine, the median interruption time lasted 46.5 seconds and was repeated an average of two times due to a failed intubation attempt (Wang 645). Interruption of CPR for such an extended period of time is less than salubrious for a patient in cardiac arrest given one should not stop compressions for more than 5-10 seconds. Furthermore, paramedics are the least trained of all clinicians authorized to perform ETIs. Studies have shown experience in performing ETIs has a direct influence on success rates (Warner et al. 103). Moreover, the minimum number of intubations performed on humans for a paramedic to be eligible to perform ETI on the field is five (Wang “Paramedic”).  Compared to an emergency medicine resident’s 35 and anesthesia resident’s 57, one can clearly see a discrepancy of standards in medical training. In short, the present evidence points towards revoking ETI privileges from paramedics, however, one must also consider the data in support of paramedic ETIs.

Keep it in the Field

Those in support of in field ETIs quickly point to multiple flaws in their critics’ data and work to provide context to both the data and the practical applications of ETIs. A common flaw found in the studies opposing the use of paramedic ETIs is the alternative treatment to which the ETIs are compared to. Most commonly, the researchers compare ETIs to the use of a bag-valve mask (BVM). A BVM, a common breathing assistance device, is simply a tool which allows clinicians to breathe for the patient without an invasive procedure. This basic life support treatment does not give full context to the patient’s condition, given a BVM is used in a variety of medical situations (JEMS 4). Furthermore, many recent studies have negated many findings that favor removing ETIs from the field. One example is a 2003 article published in The Journal of Emergency Medicine which indicates that previous paramedic experience has little to no effect on ETI success rates, a stark contrast to the talking point advanced by critics (Garza et al. 251). Yet, it is most important to provide context to the studies. Many of the studies do not take into account the chaotic environment paramedics often work in. To perform an intricate procedure in an operating room is a task in itself, let alone if one must do it inside of a motor vehicle that has been involved in a collision.

Compromise?

Clearly both sides present interesting arguments concerning the use of ETIs in field. Like with most critical issues, compromise has slated as the best solution. Further training is needed to assure the best patient care possible. This requires efforts from both paramedic students and the hospitals in which they train. The hospitals must be willing to open their doors to more students and allow them to perform ETIs in multiple clinical settings. The students, of course, must be willing to put in extra time at the hospitals and be constantly willing to learn from their mentors. Continuing Medical Education (CME) classes need to also undergo revitalization given that many paramedics do not perform ETIs frequently in field. More frequent CMEs would keep paramedics up to date on ETI techniques and science. In addition to more training, paramedics should also be taught the importance of alternative airway devices such as King airways and Combitubes. According to Wang, these devices are often less invasive than ETIs and provide sufficient airway maintenance (“Paramedic”).

Conclusions

With these compromises in mind, the debate between in field ETI use shines a light on multiple overarching facets in emergency medicine. There is a common misconception that more paramedics in an EMS system will lead to better care. However, larger amounts of paramedics make it difficult to reviewing their effectiveness and to provide sufficient CME classes. Additionally, keeping medicine simple is often the best tactic in the field. EMTs offer basic medical care without extensive training and do not perform invasive procedures that are often plagued with mistakes. Finally, the attention given to ETIs should also be extended to many procedures in emergency medicine. Evidence based medicine and clinical reviews should extend to all practitioners and their techniques, regardless of training or specialty. In the end, what matters most is that medicine is held to the highest standards. The debate of in field ETIs should serve as just one example of medicine being put under the microscope.

References

“Experts Debate Paramedic Intubation.” Journal of Emergency Medical Services (JEMS), 2010. Web. 30 June 2010.

Garza, Alex, et al. “Effect of Paramedic Experience on Orotracheal Intubation Success Rates.” The Journal of Emergency Medicine 25.3 (2003): 251. Web. 18 Nov. 2011

Gauche, Marianne, et al. “Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome.” Journal of the American Medical Society 283.6 (2000): 783-790. Web. 18 Nov. 2011.

Wang, Henry. “Paramedic Endotracheal Intubation and Health Services Research.” The University of Alabama at Birmingham, n.d. Web. 18 Nov. 2011.

Wang, Henry, et al. “Interruptions in Cardiopulmonary Resuscitation from Paramedic Endotracheal Intubation.” Annals of Emergency Med. 54.5 (2009): 645-652.

Warner, Keir, et al. “Paramedic Training for Proficient Prehospital Endotracheal Intubation.” Prehospital Emergency Care 14.1 (2010): 1. Web. 18 Nov. 2011.

Picture: http://medicmadness.com/files/2009/12/IntubationCurrent2_tcm16-210658.jpg

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