I have mixed emotions about this topic because I have seen very good airway techniques in the field and also very bad techniques in multiple services. Some medics want nothing to do with intubations while others fight over the tube. We do need to concentrate on improving our education and practice for both medic students and practicing medics. Getting OR time is difficult and medical education is increasingly moving toward simulators. I just read an article that demonstrated no difference in intubation success rates for medic students that trained on mannequins versus those trained on live patients in the OR. I'm planning on a research project with my service to improve first time intubation success rates with mannequin training.
I attended the Wang/Roth debate and have also read much of what Dr. Wang has published recently concerning prehospital ETI. There are two questions: Should paramedics intubate and can paramedics intubate? Dr. Wang asserts that the original research (circa 1980) suggesting paramedics can intubate was flawed. Recent research suggested outcomes of patients with TBI intubated by medics had higher mortality and morbidity. Also, he looked at PA medics over one year and found 40% had zero intubations for the year. The average medic had two while the average flight crew had nearly three. He also broke down the intubations by county and showed there were entire counties that had zero intubations for the year. Granted these were rural areas but zero cardiac arrests for the year is hard to believe. As far as I know these areas have ALS services.
I feel Dr. Wang is correct that the original research from 1980 was flawed but I feel he is using equally flawed data to prove his point. Every one of his studies requires extensive statistical analysis to prove his point. As Benjamin Disraeli said, "There are lies, there are damn lies, and then there are statistics." The latest edition of Prehospital Emergency Care has a position statement by the NAEMSP concerning RSI and drug assisted intubations (DAI) and is well worth reading. Dr. Wang has a follow up article on the position statement reviewing the literature. He admits the research is equivocal.
Dr. Roth (a well known and respected local medical director) feels that intubating is like riding a bicycle; once learned you never forget. Dr. Wang (a well known and despised local ER doctor) disagrees with this analogy unless it applies to himself. He readily admits that he does only a "handful" of intubations in a year but he relies on the many tubes he got during his training a few years ago. Sounds like a contradiction to me. I would bet that most ER physicians do fewer intubations in a year than medics but Dr. Wang will not study this because it would create trouble for his peers when it is easier to pick on medics. Crap rolls down hill and medics are standing there with a bucket.
End result is we should not change our practice because of one or two studies by the same investigator who may be biased. We as medics must work to improve and maintain our skills at a high level. We need solid QA/QI procedures in place to identify problems and intervene early to correct deficiencies with our training. PA seldom leads the pack in anything but we may take the lead here by removing ETI from the medic's scope of practice. Most unfortunate.
On a side note, if anybody has the chance to use a King LT-D airway jump at it. We've been using them in the OR in place of an LMA for a few months and I think they are superior to the LMA and combitube. I think they have great utility for prehospital use and could be used by basic EMT's.
Live long and prosper.
Spock