Monday, 2 February 2015

Focus On: The Great Paramedic Intubation Debate

So if you're studying to become a Paramedic, it's very likely that you've heard about the great debate whether we as a Profession should Intubate patients anymore. The following is a whistle stop tour of how all of this came about and some of the issues around it.

Read on to find out more...

After a few reports of Oesophagal Intubations during Resuscitation efforts, and the Clinician failing to recognise that they were ventilating the patients stomach rather than their lungs - the Joint Royal Colleges Ambulance Committee (JRCALC) 'Airway Group' looked at some research that was out there. The information suggested that when the Paramedic doesn't routine intubate or practice on simulation aids, that they suffer significant skill fade in around 3 months of not doing it. This is then compared to the use of Supraglottic airway devices such as iGel and the Laryngeal Mask Airway which there was very little skill fade from, they then suggest that Paramedic Intubation is a legacy procedure that only exists because when it was introduced there were no other comparable alternative interventions and that we as a profession, should move with the times and shelf the skill.

The College of Paramedics then hit back with it's own response to the JRCALC Airway Groups research and cites it as flawed and using selective evidence only. It states that most of the evidence is based on US Paramedics where the standard of training and education is very different, and that the conclusion of the report is based on group consensus which is seen as a poor scientific method in the 'Heirarchy of Evidence'. It also states that a search of the Medline data base would yield hundreds of results for 'Paramedic Intubation' yet the report only used 60 or so pieces of evidence to reach it's decision (which is where the selective evidence bit comes from). So understandably, a Paramedic in the UK would be rightly confused about what he or she should be doing and concerned if they are actually harming their patient - when the two big hitters in Paramedic representation and regulation are going at it with completely opposite views, who could blame them?

Since then there have been more and more studies carried out, one of the most recent used was a randomised control trial (which is seen as one of the best types of evidence to use) in the UK between Endotracheal Intubation and use of Supraglottic Airways and it reported no significant difference between the two. With this being the case, there is a strong argument that Intubation should remain in the Paramedics scope of practice, the use of a Laryngoscope is still essential to assist with the removal of foreign bodies in or above the vocal cords and whilst Intubation can do everything a Supraglottic airway can, the reverse isn't true. Ultimately it is generally conceded that a good step-wise approach to airway management should be adopted and the modern Paramedic should not be having skills or equipment taken away when the evidence doesn't support it.

Comparison of Tracheal Intubation and other Airway opening devices pre-hospitally
JRCALC: A Critical Reassessment of Ambulance Service Airway Management in Pre-Hospital Care.
College of Paramedic response to JRCALC Airway Groups Findings

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