“A” is for airway … Also for action☆
Article Outline
Abstract
[Delbridge TR, Yealy DM. “A” is for airway … also for action. Ann Emerg Med . January 2001;37:62-64.]
See related article, p. 32 .
As Mick “Crocodile ” Dundee was preparing to go on walk-about through the Outback, he had to ask his best mate what day it was so he would know when to return. His mate commented how lucky Mick was, “Doesn ’t know; doesn ’t care. ” In this issue of Annals , Katz and Falk1 describe a similar problem common to many emergency medical services (EMS) systems. It’s not that they don’t care; they don’t care to know.
We commit ourselves to the “ABC” approach to initial assessment and attempts to resuscitate seriously ill or injured patients. It forms the foundation for the most basic first-aid and cardiopulmonary resuscitation (CPR) courses, and even the practical education we provide new physicians. We strive to ensure that the ABC approach is integral to the practice of emergency medical technicians (EMTs) and paramedics. “A” is for airway … the first step. Although concerns continue regarding the proven value of many EMS-provided therapies, there is little doubt about the importance of maintaining the patency of each patient’s airway. There is some debate over the most appropriate technique for approaching this problem in specific circumstances, such as for pediatric patients or patients in cardiac arrest.2 Whatever procedure is used, it must be successful. For more advanced EMS systems that deploy paramedics, use of endotracheal intubation (ETI) is commonplace. For the past 2 decades, we have professed our abilities to train EMS providers to be proficient in this skill.3
Clearly, we remain cognizant of the risks of performing ETI outside controlled settings in hospitals, especially for patients who are not in cardiac arrest. One manifestation of that awareness has been hesitancy to authorize EMS providers to use neuromuscular blocking (NMB) agents to facilitate ETI. Currently, among EMS systems, the availability of these agents is limited and often reserved for specific situations, such as air medical services.4 If our confidence in EMS providers was without question, would we not incorporate the use of NMB agents into their practice with less hesitancy? On the other hand, the risks to patients, those for whom we advocate, are real.
There is always the potential of failure to intubate. Even more disastrous is the potential for failing to intubate the trachea and not recognizing it. In every setting, we focus on avoiding such an eventuality. In the operating room, arguably the most controlled setting possible for ETI, this issue has been addressed decisively.5 Detecting and monitoring end-tidal carbon dioxide is the standard of care for patients who undergo ETI. However, there is no such standard or routine practice for EMS systems or even our emergency departments. It is nothing short of amazing that physicians use the most reliable technology in the environment that can be the most controlled and is the most conducive to effectively examining the patient to determine the success or failure of the procedure. In contrast, we send EMS providers, often with limited experience, into the most treacherous environments, sometimes to places we would never dare to venture, and expect them to perform under conditions we would never tolerate. There, the ability to clinically determine the success of ETI is least. Additionally, valuable tools are not made available or are not used predictably.
In the operating room, most intubated patients never move. Control is at a maximum. End-tidal carbon dioxide is monitored throughout each procedure. In the field, EMS providers, when they use them, often rely on various ETI detection devices for single spot determinations. Have we not placed our priority in the wrong place? Previous calls have made to evaluate the means by which we expect EMS providers to detect and monitor ETIs.6 Is it not time we ensure that our EMS systems use the most reliable technology for such a critical situation and intervention and expect EMS providers to predictably use the tools they are provided?
The EMS system leadership and the providers themselves should have already known what the Katz and Falk1 article pointed out in this issue of Annals. The need for their work should have been obviated by ongoing quality improvement activities. The intervention studied, ETI, is critically important. Presumably, a number of the involved patients were in cardiac arrest. Some might argue that ETI may not be important for this specific population of patients and that subsequent concern about proficiency is unwarranted. However, for whomever the procedure is attempted, patient risk is obviously considerable. So, for the EMS system Katz and Falk studied, where were the efforts to monitor patient outcomes, individual providers, and EMS system components (eg, the various participating agencies) and processes? Why was the use of available detection devices “sporadic” and what was being done about that? In short, before Katz and Falk, who cared to know? More importantly, who cares to know in each of our own communities?
We hold ourselves accountable for the care provided in our EDs. Part of our professionalism entails evaluating our own quality. Given the sophistication and importance of their work, the same should be expected of EMS systems. The challenge remains to instill such an expectation within the culture of EMS providers. There should be a focus on those who are in training and those who are seasoned without indoctrination into self-evaluation and responsible critique of interesting cases. As is the case in the ED, we must continue to ensure that evaluation is an integral part of every EMS system.7
In the situation described by Katz and Falk,1 where were the physicians? For the past 2 decades, we have been purporting the importance of physician leadership in all aspects of the EMS system. Some investigators have linked system performance and patient outcome improvements to EMS physician involvement.8 As emergency physicians, we believe that our connection to the EMS system is one aspect that distinguishes us from our non–emergency physician colleagues. In each of our communities, where is the physician leadership and oversight of the EMS system? Are we fulfilling our own responsibilities to the communities and EMS systems we serve? For some, this might merely mean being responsive to the EMS system and its medical director to provide timely feedback. For their part, we must be assured that EMS system medical and administrative leadership are receptive to responsible input and are prepared to act accordingly.
Over the course of 8 months, Katz and Falk1 were able to document 27 patients with endotracheal tubes that were misplaced by EMS providers. They indicate that they have used their findings to seek EMS system improvements. In the operating room, and in the ED, an unrecognized esophageal intubation would be considered a sentinel event, necessitating extensive documented effort to avoid a recurrence. Clearly, as findings such as Katz and Falk1 are being realized, an ethical dilemma is manifest. For research studies that involve comparison of 2 therapies, there must be an option to discontinue the study if interim results indicate clear superiority of one over the other. There are no equivalent standards for observational studies. However, investigators should obligate themselves to establish a priori guidelines for their studies to indicate when the observation might be abandoned in favor of advocating for improvement.
Katz and Falk’s report1 leaves us with questions to which we do not know the answers. We do not know what quality improvement initiatives preceded the study. We do not know why this problem had not been previously recognized. We do not know what emergency physicians had done to help before this. We do not know how similar-sized communities and EMS systems would fare under similar scrutiny.
We do know that “A” is for airway. We have the technology to improve the means by which EMS providers can determine the success of their efforts and monitor intubated patients. EMS system leaders should care to know, and evaluation must be integral to the cultures of EMS systems. Physician leadership of EMS systems is essential and all emergency physicians have a responsibility to help oversee the EMS system. We do know that “A” is also for action.
References
- . Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001;37:32–37
- Effect of out-of-hospital pediatric endotracheal intubation survival and neurologic outcome. JAMA. 2000;283:783–790
- Field endotracheal intubation by paramedical personnel. Chest. 1984;85:341–345
- . Out-of-hospital use of neuromuscular-blocking agents in the United States. Prehosp Emerg Care. 1998;2:29–32
- . Standards for basic anesthetic monitoring, October 1998. Available at http://www.asahq.org/standards/02.html#2September 15, 2000; Accessed
- . Confirmation of airway placement. Prehosp Emerg Care. 1999;2:273–278
- EMS agenda for the future: where we are … where we want to be. Ann Emerg Med. 1998;31:251–263
- The effect of full-time specialized physician supervision the success of a large urban emergency medical services system. Crit Care Med. 1993;21:1279–1286
☆ Reprints not available from the authors. Address for correspondence: Theodore R. Delbridge, MD, MPH, Department of Emergency Medicine CL-13, University of Pittsburgh Medical Center-Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15220; 412-647-1107, fax 412-647-5053; E-mail delbridget@msx.upmc.edu.
PII: S0196-0644(01)17262-8
doi:10.1067/mem.2001.112945
© 2001 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Misplaced endotracheal tubes by paramedics in an urban emergency medical services system
