Tuesday, July 26, 2005

Intubation Article

Interesting article in the Pittsburgh Papers about the trouble paramedics have with intubation.

Paramedics lacking experience
Intubation at issue in study


Paramedics lacking experience
Intubation at issue in study
Tuesday, July 19, 2005

By Jacqueline Shoyeb, Pittsburgh Post-Gazette

Many Pennsylvania paramedics don't get enough experience intubating patients, a new University of Pittsburgh School of Medicine study has found.

The report may help explain results from an earlier study that found that patients intubated in the field are more likely to die than those intubated in a hospital.

"I think we need to be worried as medical educators. We have this complex procedure, and we think it's critical for paramedics to perform this procedure. And we're finding out they may not be skilled enough," said Henry Wang, the study's lead author and an assistant professor of emergency medicine at the school.

The study, published in the August issue of the journal Critical Care Medicine, reports that two-thirds of Pennsylvania paramedics performed the procedure three times or fewer in a year. And 40 percent never intubated a patient within a year's time.

Wang said that lack of experience may be one reason for findings from a larger study done last November.

In that study, university researchers found that Pennsylvania patients with traumatic brain injuries who were intubated in the field were four times more likely to die than those intubated in a hospital.

But paramedics here and nationally say more training is preferred in any field, and that overall, emergency rescuers are doing a good job.

Endotracheal intubation involves inserting a 12-inch plastic tube down a patient's throat to pump air into the lungs.

In the 1970s, Pittsburgh paramedics were among the first in the nation to use the procedure outside a hospital to help keep trauma patients alive.

Wang and the other researchers gathered their information from the Pennsylvania Emergency Medical Services Patient Care Report, a database of all emergency medical service patients in the state.

They counted the number of successful intubations done by 5,245 rescuers in 2003.

The report doesn't record unsuccessful intubations.

From the database, researchers calculated that the median number of intubations done by a rescuer was one.

Wang said paramedics need more experience and training or find better methods of opening the airway.

But one of the challenges with that is agreeing upon the right number of intubations that should be done before a paramedic is declared certified, said Daniel Gerard, past chairman of the Paramedics Division of the National Association of Emergency Medical Technicians.

Gerard, a 20-year paramedic, said he estimates that rescuers need to perform it on mannequins or cadavers about 12 to 20 times.

U.S. paramedic students only need to perform five intubations before graduation. In comparison, nurse anesthetist trainees need to perform 200.

Gerard, who also is an associate professor at George Washington University, warned that Wang's study is only a one-year snapshot of one state. It shouldn't be applied to paramedics in the entire nation, he said.

"I would say for the entire profession, we're doing all right," he said.

Paramedic training officer Paul Sabol, with the Pittsburgh Bureau of EMS, said he has faith in the city's paramedics.

Sabol, a 23-year paramedic, said he can't argue against more training, but said that Pittsburgh paramedics get enough experience to meet certification requirements.


Here's the Abstract


Title: Procedural experience with out-of-hospital endotracheal intubation

Author(s): Henry E. Wang MD, MPH; Douglas F. Kupas MD; David Hostler PhD, NREMT-P; Robert Cooney MS; Donald M. Yealy MD; Judith R. Lave PhD

Objective: Out-of-hospital rescuers likely need regular clinical experience to perform endotracheal intubation (ETI) in a safe and effective manner. We sought to determine the frequency of ETI performed by individual out-of-hospital rescuers.

Design: Analysis of an administrative database of all emergency medical services (EMS) patient care reports in Pennsylvania.

Setting: Commonwealth of Pennsylvania from January 1 to December 31, 2003.

Subjects: EMS advanced life support rescuers (paramedics, prehospital nurses, and EMS physicians) who reported at least one patient contact during the study period.

Interventions: None.

Measurements: We calculated individual rescuer ETI frequency and opportunity. We evaluated relationships between ETI frequency and the number of patient contacts. We also examined the relationship with practice setting (air medical vs. ground rescuers and urban vs. rural rescuers).

Main Results: In 1,544,791 patient care reports, 11,484 ETIs were reported by 5,245 out-of-hospital rescuers. The median ETI frequency was one (interquartile range, 0–3; range, 0–23). Of 5,245 rescuers, >67% (3,551) performed two or fewer ETIs, and >39% (2,054) rescuers did not perform any ETIs. The median number of ETI opportunities was three (interquartile range, 0–6; range, 0–76). ETI frequency was associated with patient volume (Spearman's &rgr; = 0.67) and was higher for air medical (p = .006) and urban (p < .0001) rescuers. ETI frequency was not associated with response (Spearman's &rgr; = -0.01) or transport (Spearman's &rgr; = -0.06) times.

Conclusions: Out-of-hospital ETI, an important and difficult resuscitation intervention, is an uncommon event for most rescuers.


I am surprised the numbers are as low as they are. I was expecting them to be low, but not that low.

I have wavered back and forth on the issue of what is better more medics or fewer but more experienced medics.

I have to say I am more inclined now to go with the experience.