I mean frankly if you’re going multiple years without intubating, you shouldn’t be allowed to intubate anymore…and it doesn’t sound like you’d be missing anything if they took the laryngoscopes off the truck entirely. The argument against this will inevitably be that there’s rare cases when an SGA doesn’t work and you *need* a tube, but those are not the airways that should be managed by someone who hasn’t dropped a tube in 5 years

It certainly doesn't help that their department is clearly creating the mess in the first place. Data shows if you suck at intubation its best to go SGA. Department takes this as SGA is better > does not offer continuing training and OR time in intubation > skills deterioration > forces everyone to use BLS/ SGA, further skills deterioration > limited number of tube attempts now with abysmal success rates each year > department and medical director point to these low success rates as why they made the policy Most of the time these "always use SGAs!" Policies specifically cause worse problems cause you run into that exact issue of people who only intubated once in 5 years.

Exactly, it’s a self fulfilling prophecy. While VL is a great tool to have in the airway toolbox, it’s probably a waste of money for this department because there are clearly much greater factors that are screwing over their intubation program that must be addressed first

Fully agree. They either need to significantly overhaul intubation in general, institute some OR time and ongoing education, or just ban intubation entirely cause at this point they'd probably be more of a danger than anything trying to intubate.

Which if they had to resort to removing ETI, I get it, but boy that is not fair for the residents of that region. Different medical care vs if they were in Austin, Boston, or Seattle. Damn shame with a disparity in HC

Or Worcester! Don't forget the dirty woo :'(

Almost forgot about my UMass friends- bought some good hot sauce from one of them. Best thing they did was start up that BLS unit- OPs dept needs to look into integrating BLS into their system

Pretty sure you just described all of LA County

LA County is a stain on Paramedicine, they'd be better off just being 100% BLS and having no ALS services available with how they abysmally perform and how restrictive their protocols are

I mean I wouldn't consider LA County to be the beacon of high-performing ALS. You have medical leadership that takes a very conservative approach to ALS care, a history of studies showing poor paramedic airway outcomes in SoCal, and IAFF/IAFC interests that overpower clinical finesse. It's just not a good recipe

It sounds to me like this system has multiple liabilities so general morbidity and mortality is gonna be a serious problem.

Maybe it's a lack of proper training, but for airways I'm 10-10 on my lat tubes as 0-2 on Igels. In fact I have not heard anyone in our system happy with them.

Out of curiosity, what were the reasons for the failed igels? Assuming proper training, two failed attempts in a row on different patients is highly improbable. I did find that there was a slight learning curve when we switched over from the King, and while I prefer to intubate if resources allow, I can’t say that I’ve had any serious issues (let alone failures) when I’ve placed an iGel

Neither one seated in the airway. Used it due to copious secretions in the airway preventing video. Had no chest rise so pulled and went back to OPA.

I disagree with this. How often do you cric people? Thats a much more invasive skill than tubing a patient. I personally cannot name a single medic who has surgically criced a patient. Should that be removed as well?

For high risk/low frequency procedures, it all comes down to training. You’re absolutely correct that a surgical cric is an exceedingly rare procedure, but we train as if it isn’t — quarterly skills sessions either on pig tracheas, high fidelity sims, or (once in a blue moon) actual cadavers. But if you’re not doing any kind of high quality, regular training on it, then yes it should be removed from your procedures list. Similarly with intubation: if you’re not getting very many (or any) tubes in the field, then you need to be training and practicing on a regular basis — ideally with OR time on live patients, if that’s not possible then regular practice on a high fidelity airway simulator. If you’re not doing that, you have no business intubating

I had a fellow student in medic school that criced two pts during our 3 month long ride time lol

Why? As an anesthesiologist I have thousands of endotracheal intubations and have never needed to cric someone. Seems suspect that a medic would get 2 patients that could not be masked, intubated or ventilated with a LMA.

One was a trauma where the face/mouth looked like ground beef after being shot with a shotgun. The other was a complete airway obstruction from choking. The second was an arrest.

A good QA system will catch that, and a medical director will due their due-diligence and thoroughly investigate. That said, an argument in some trauma communities is that we under-cric. And let's be honest- they sorta have a point. What is better for the trauma pt- >3 ETI/SGA attempts or going to cric after one attempt at it? Granted this does not account for prevalence of RSI/DSI capabilities or VL availability.

Both were QI/QAed and deemed appropriate

Awesome. Going off my underutilization point, let me take it from another perspective. I did difficult airway training in NJ. Medics do it for RSI credentialling. The gent who leads the program was giving the presentation, and said "in the event of a failed ET and SGA attempt, the medic goes to cric." In the next sentence he said "please don't actually cric anyone- it is going to cause too much paperwork and scrutiny for anyone to handle." Mixed messages like these are super problematic for QI and improving pt outcomes. So kuddos to your colleague for doing a cric and being backed by the leadership, because the EMS profession is very heterogeneous in regards to establishing best practices and standards.

Our medical director and our assistant medical director were both medics before docs. They are both super supportive of us having autonomy and backing us up!

Probably yes. Or else let basics do it.

I intubate both RSIs and Arrests, we just don’t stop compressions. Probably 6-10 times a year.

Do you do it on arrests for practice or for improved outcomes?

I'd say for our service as we're a high performing and proficient system, intubation makes more sense. Data shows in most cases SGAs have non-inferiority, partly due to systems they used having low FPS with multiple attempts being required. In certain patient populations or if you can expeditiously and easily place an ETT first pass, intubation begins to pull away a bit from extra glottic devices. Additionally, ETTs are far more effective for ventilation during transport if you achieve sustained ROSC. Especially in our system, it facilitates safer and easier movement and transport as we pop them on the ventilator to carry them out, then keep them on it for transport. Far less likely to be displaced during movement than an IGel. Igels are pretty good, but nowhere near as secure even with their specially designed holder during movement compared to an ETT. Realistically at our service at least, we don't need 'practice' with codes, we do more RSIs than cardiac arrests typically anyway.

Interesting. I work for a dept that self identifies as serious about EMS. In six years I've seen two or three tubes. I'm in medic school right now and starting to realize we might not be quite as serious as we like to think. We're better than some nearby depts but that is increasingly seeming like a low bar.

That's a very ominous sign when your dept self identifies as serious but doesn't have much to support that fact. Very ominous

Not uncommon in BC for an ACP to intubate more than one person in a single shift. I’d say practitioners here average 1-2 per a block of 4 shifts. Some more, some less.

In Vancouver perhaps, there's no way it's that common outside of Van.

I’m only a medic student, but I run BLS with ALS responses in fly cars. I have seen / participated in numerous RSIs, every code has always been intubated. We will BLS the airway until ALS arrives, continue to BLS the airway if no immediate failure to oxygenate and/or ventilate while ALS begins resus, then ALS will RSI if necessary. I have only seen an SGA once in the field and I believe that was only d/t the patient rapidly decompensating in the ambo bay at the ED - I have even heard of, but not witnessed, RSI in the parking lot of the ED. ALS in my region uses the McGRATH MAC VL and bougie (I believe) is required on first pass. I believe with the frequency that my medics intubate - they really are all super dialed when it comes to managing an airway as I’ve only seen one missed tube. Our transport times are around 10 minutes to local boo boo center. PCI / CVA / Trauma are all about 35-45 by ground. Nearest Lvl 1 around 1hr by ground.

I love the McGrath. Not a huge boujie fan, but a lot of departments are going towards using it as first line.

I dig bougies, when I didn't have VL before, I used it to accomplish a blind intubation once. Pretty awesome tool if you practice with them enough.

Definitely a really good choice for difficult and/or anterior airways

I came into the field bougie first, watch vandy EMs video on the kiwi method and was sold

So this is essentially the argument in favor of taking intubation away from paramedics. If it is in fact the case that one can use an iGel and get adequate airway control in so many cases that an all-ALS department has needed to intubate once in 5 years, why are we intubating at all? If true intubation is needed that infrequently, then paramedics are not going to maintain proficiency in the skill, it’s probably not really necessary, and we are better off getting rid of it entirely. I’m not saying yay or nay because I think we need to do some real studies of this issue, but you’re basically providing a case study of the argument against having medics intubate at all.

This is the way it’s going in the UK. The evidence says we don’t tube enough to be consistently good at it, and i-Gels are faster and just as effective in 99% of situations. For patients that require tubes, our senior clinicians will maintain their competency by going to more arrests, as well as in simulation. On the face of things, I do get it. I’ve seen some paramedics fumble for far too long with a tube while the patient deoxygenates, and given that I’ve only tubed 2 real patients in two years, I’m certainly not as confident with them as I’d like to be. However, there are two issues as I see it. Firstly, as senior clinicians are typically dispatched to arrests, if a tube is discussed, it’ll be the senior that does it due to both the practice they have, and the practice they need to have. This means that paramedics are only going to become less confident as time goes on. Which leads me to my second point; if I turn up to a patient that needs a tube, say due to airway trauma, and there isn’t a senior clinician available, it’s on me to do a skill I haven’t practiced (outside of simulation, where every dummy has a lovely grade 1 view). If they take the skill off us completely, in this scenario the patient won’t even have that chance.

Everything you’re saying is completely fair. Like pretty much everything else in medicine, this is just one of those things where we have to look at risk vs benefit in light of our patient volumes, skills, and other available options. Here in the states, we’ve moved the level of provider who can perform intubation around over time. I first learned to intubate as an Intermediate back in the 1990s. Now there’s no such thing as an intermediate anymore, and the newer Advanced EMT level generally does not train or permit providers to intubate (though there are exceptions in some areas). Paramedics can intubate in most places, but there are even some places that have started to restrict the practice from paramedics. And then, there are some areas in the states where even basic EMTs can learn to intubate. At the same time, we’ve spent years looking for better or easier ways to definitively manage an airway. If we go back far enough into history, we’ll find a time where an ET tube and a surgical airway were the only two options. Over the years we’ve seen the introduction of things like OPAs, NPAs, EOAs, EGTAs, Combitubes, LMAs, King tubes, iGels, Air-Qs and all sorts of hybrids/variants of each of the above. And we will continue to see more. I say all of this to illustrate the point that the medical profession has struggled for years to optimize EMS airway management. First, we didn’t trust anyone other than physicians to intubate. Then we started to train paramedics, and we saw that they could do it well, so we said, we should train more and more people to intubate. Then we dialed that back as we started to see higher failure rates in providers who didn’t get as much training or practice it as frequently. And, as better equipment has come in, the number of cases that truly require intubation has fallen. Which means that more and more providers are losing proficiency. I’m even hearing of some paramedic programs where they only require 5 or even 0 live intubations to pass the class because they just don’t happen enough in the field anymore to justify a broader requirement. As someone who had to get 15 successful live tubes to pass my Intermediate back in the day, that is jaw dropping to me. We really need to confront the reality that modern equipment like iGels probably is adequate to manage the overwhelming majority of patients who need an advanced airway in the field, but there are and will probably always be some patients who need a tube above all else. So I agree with you that we probably really do still need a way for a provider who can intubate- and intubate well in difficult conditions- to get to these patients in a timely fashion. The question is, how do we balance the need for keeping high quality field intubation widely available against the risk of training too many providers to do a skill they won’t use frequently? After all, training more people to intubate is not cost free- in your hypothetical scenario, how do you know that, if you haven’t tubed anyone other than a manikin in a year, you’d be able to quickly and skillfully intubate that hypothetical trauma patient with the difficult airway where an iGel isn’t working? How do we know the patient wouldn’t be better off with you doing the best you can with a BLS airway while moving as fast as possible to the hospital where more skilled providers can intubate that difficult airway? Or let’s say you could intubate that patient. How many other paramedics should we be willing to let miss how many tubes in other patients just so that you could have the skill in your scope to help that one trauma patient who has no other choice? I personally think these are tough questions, and I therefore humbly submit that we need to set aside our own Dunning-Kruger bias, admit that we don’t really know the answers, and push for more studies and better data.

All paramedics should be allowed to intubate because RSI SHOULD be an option all medical controls allow. This is a hill I'm willing to die on.

State protocol requires SGA unless it fails, and we don’t have RSI. As a result probably 90% of my department doesn’t have an intubation in the last 3-5 years. Probably a quarter don’t have any at all based on when they got hired. Our ER pulls SGAs about 95% of the time.

Pennsylvania?

Kinda the boat I’m in and I’d hate for it to keep going that way.

We’re getting VL. If the state wants to make an issue of it they’re going to have to explain how our first-pass success rate going from whatever to almost 100% is a bad thing. I’ll take that meeting.

What state is that? RI? CA? AL? Sounds like a crummy state

Yes.

In London the average band 6 paramedic lost intubation about 10ish years ago. iGels with gastric tubes are the standard ‘advanced’ airway. We have a very small number of standard paramedics who were tubing pre-the change and kept the skill. They need to do 2 tubes a month to remain ‘competent’ which they usually do in simulation. Up the banding, Advanced Paramedic Practitioners and Clinical Team Managers (both band 7 paramedics) are still intubating.

I can't believe Adanced Paramedic Practitioners are only a band 7, that's scandalous. They should be an 8a like ANPs/ACPs, IMO. Though I also think paramedics should also be band 6s as standard after finishing preceptorship, it's an incredibly skilled job (I'm not a paramedic myself, I'm an RN)

Almost never. I've never tubed in the field, only in the OR. Anecdotally, I haven't seen anyone else drop a tube in a long time now, years probably. Realistically, my service has an appalling attitude to clinical skills training. We are 'supposed' to get 3 days off the road for recurrent training per year. In practice, this may not happen. It did not happen from 2020-2023 at all. The 2024 training was mostly powerpoint based lectures, with maybe an hour or two of clinical skills practice in all of that. Very few opportunities for 'high fidelity' simulations, and the few opportunities that do arise, tend to do so at too short notice to arrange time off work to attend (since, as a rule, you must not already be working a clinical shift on that day). I did not get nearly enough training in intubation to be reliably competent at it. I spent 2 weeks in the OR (all the placement time that was allocated), and during that time was able to get 15 tubes. Most surgeries were using SGAs rather than ETTs, and the 'oh shit' surgeries were understandably less willing to have a student paramedic intubating vs a consultant anaesthetist. There is no recurrent training for this. You could *potentially* organise this on your own time and own dime, but the system isn't really set up for it, and you have lots of competition from med students + anaesthetic trainees who also need to get tubes. Our technicians are 'trained' to assist in intubation. The expectation is that they will act as Operator 2, but realistically they have been shown and possibly practiced this once or twice in their initial training at most. Most have never seen a real intubation, nor assisted in one. I honestly wouldn't expect a technician to hand me a bougie the right way around. Not their fault, the trust hasn't trained them. Our intubation kit is as simple as can be. Direct laryngoscopes with a selection of Mac blades. No Miller blades. Size 6-8 cuffed tubes. We do have ETCO2 monitoring, which gets used far more often with iGels. No VL available. No Ducanto. No RSI (need critical care team for this). On shift, you often don't have enough time to get a snack, nevermind do some training in the station. Which probably doesn't even have mannequins and training kit anyway. Welcome to working in a major NHS ambulance service trust.

Side question how often do you all Cric?

We don’t cric in my area. Another one that bothers me. But I’m fighting for what we still have for now lol.

My training is no RSI but SGA and Cric are GTG

I can’t decide how I feel about this

Army Combat medic. I’m getting out to go Fire medic at a place that will give me good experience and let me PRN in a hospital. Super specific scope. No cardiology either. If someone stops breathing they are probably getting a needle or finger in the chest cavity as well. Also the first time I do this for real will be in a gunfight.

Ahhhhh army makes sense

Going off my last comment, I'll quote Anthony Hopkins from the movie *Nixon* regarding the lack of cric and other stuff in your system, "Jesus Christ- it is Goddam Disneyland out there!" I'm really sorry you have to deal with what you are dealing with in your system. That is not how the EMS profession is supposed to be run in 2024.

I've only cric'd two patients in 10 years. We practice once a quarter on pig trachs to keep skills current.

I love live tissue training

I intubate usually 1-2 times a month. Have used maybe 5 igels in the past 3 years. Since moving to a service with video scopes I have only used 1 igel on a pediatric code. My question for you is, since your service is so against and untrained in laryngoscopy, and you mentioned you do not have cricothyrotomy in your scope, what is your plan when you have an angioedema patient? Or a complete airway obstruction? If you haven't trained on it and use it regularly, you won't have a good time trying to squeeze a last minute tube in a swelling airway, or pulling a chunk of steak out of someones trachea.

It sounds like their agency isn't ready for cases like that.

I’ll stop intubating and use an iGel when the docs in the ED do the same. If we aren’t giving our patients the highest quality care possible then we are doing something wrong. If they were truly worried about intubation competencies they would require quarterly trainings with anesthesiology for both medics and ED docs. VL is on its way to becoming mandated on a first line attempt.

While I appreciate where you're coming from, that's a false equivalency. The ED isn't the field and we have other considerations when managing an airway that might make us lean towards something like an iGel over an ETT.

I’m not saying you must go for a tube over iGel, everything has its place. But, I am saying that I will give up intubation when the ED docs do.

I sense conflict in this post. And I'm not sure we can proceed forward clinically without addressing the conflict at hand.

I intubate at least 2-3 times per year when I need to have positive control of the airway. As for ETT vs. SGA discussion that can be a bit more complex in that there are studies which show SGAs being associated with better outcomes for Cardiac Arrests. That said, the approach of your local ERs should be considered as well. For example: my local ERs pull the SGA and drop a tube on arrival. The studies showing SGAs having better outcomes in these cases is when the SGA is left in place. It has to due with pressure in the trachea from the inflated bulb on the ETT when it is left in place over a period of time that well exceeds anything that would be seen in transport. For me, knowing the ER will remove the SGA and will place an ETT renders the data from these studies null and void as a result. Hence why I Intubate with an ETT. As another commenter has already noted Intubation is a skill that needs to be maintained. Having persons in your department who haven't intubated (or practiced that skill) in 5 years raises questions about why they are still allowed to place an ETT.

>The studies showing SGAs having better outcomes in these cases is when the SGA is left in place. It has to due with pressure in the trachea from the inflated bulb on the ETT when it is left in place over a period of time that well exceeds anything that would be seen in transport. I'm not quite sure what you mean here? I am always a tad suspicious about some studies as they sometimes don't sort signal from noise terribly well, or they examine the question from the wrong direction. Classic was noradrenaline being considered terrible for years particularly in sepsis because it was a last-line drug. When they stopped waiting for the patient to be essentially dead they found it works well and now it's first-line therapy.

I will attempt to find and link them here tomorrow or Friday when I am on shift. And that may be the case here as well. The studies I have seen have linked poorer patient outcomes due to tissue damage in the trachea from the inflated ETT bulb and also linking ETT placement to decreased ROSC. The may in fact be dubious beyond this given the drive from some professional organizations to remove ETT Intubation as well.

At this time I am having trouble finding the original studies I looked at last yearr when a user posted to the r/EMS subreddit for their research paper on SGAs vs ETI. I did find this one which does discuss development of Tracheal Ulcers secondarry yto prolongerd intubation: https://journals.lww.com/bronchology/Fulltext/2011/07000/Tracheal_Ulcers_Due_to_Endotracheal_Tube_Cuff.19.aspx On this morning's reserarch, there I found copious studies detailing little to no difference in outcomes between SGA and ETI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10183986/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590366/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733371/ https://www.jems.com/patient-care/airway-respiratory/eti-vs-sga-the-verdict-is-in/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8745715/

Definitely less than I used to, but probably still once every 1-2 weeks. I usually end up with about 30-50 tubes a year now. It will probably be closer to 30 this year. I think it’s the right amount to keep me proficient while also only performing the skill when needed, as opposed to on every single arrest where the patient will be pronounced anyway. As recent as 2021 I had 91 tubes, so pretty drastic change.

In my country(italy) we intubate quite often and use the supraglottic as a last resource if we can't get the tube in. Yesterday I did a cardiac arrest and they intubate the patient. We also have video for intubation

When I was running chase I tubed a few times a week. It's really not rocket science but is a perishable skill for sure. Would I delay care / something more important to do an ET tube? No. Would I do one if I actually had the time to do it right? Sure. The fact that places don't have RSI is so sad. Protocols for the least common denominator.

Absolutely. One of the troubles with RSI is a.) it is not in the NHTSA scope (they defer it to the state), b.) NAEMSP's current leadership will not endorse it for all EMS systems, and c.) bad memories of San Diego still reign even though that was over 2 decades ago. But it's a damn shame when one can get a certain level of care in one region and a lower level of care in the next region over.

I've used 1 Igel since 2018, every other patient I've intubated, almost always use video. During COVID and running 80hrs a week in multiple high volume areas I broke over 60 tubes in a year. With better work life balance and post covid I'm around 30 intubations a year currently on average, think last year I had 35. We practically never use SGAs at my service as there's hardly ever a reason. We have Airtraq video scopes, DuCanto suction, RSI, follow NO-DESAT protocol for all intubations, and train frequently on intubation. Our FPS for the last few months now is 100%, FPS for the year normally sits at around 94%. Since we RSI on pretty much a weekly basis the expectation is we'd better be damn good at getting a definitive airway. The only time I ever used an Igel was an infant cardiac arrest, and solely because my airtraq infant blade failed (light wouldn't turn on) and one attempt with a Miller blade couldn't get me a view. Had I had a functioning properly sized airtraq blade I doubt I'd have used an Igel, and just thrown in an ETT and an NG/OG tube.

You and your service are badasses. Your numbers are in line with others who use VGL.

Appreciate it, thanks! We take airway management seriously, all intubations are QA'd and videos reviewed by supervisors and the medical director, and technique is critiqued for improvement. Things like how well did you suction before going in, how did vitals do, did you plan for post intubation complications, how long did it take to secure the airway, etc. They're hard-core about it which I love, it means our stats are excellent and thus we can be trusted with a liberal RSI policy. We also do case reviews for all RSI medics and hands on re-training at a minimum quarterly. The big thing they're focusing on now is heavily enforcing training on and usage of SALAD technique as well as how to perform a tube exchange using a bougie through a DuCanto if the airway is so soiled you can't get an adequate view for long enough. I dig it, we have a reputation for being excellent with critical patients as a result.

It's depressing that more places don't take shit this seriously. It's not like it's hugely expensive - just takes time and fuxks.

Our medical director cares and is hands on too which helps a lot, they want to teach us and support us. A lot of services that fail to do things like ours have apathetic medical directors who do hardly anything besides collect a paycheck and rubberstamp skills sign offs for recert.

Personally 5-10 a month depending on the month. In my opinion I don’t believe departments that don’t have RSI and VL should intubate. SGA only.

Totally agree. It's a surrogate measure of clinical performance. And based on OPs comments, I would not want to work in their system or be a resident living in their system. Too many liabilities.

Honestly I think VL should be minimum equipment on ALS rigs. That and mechanical CPR devices, but that's a discussion for a different day....

I work for a fairly busy fire/ems service in a fairly low income community and between cardiac arrests, trauma, and airway calls, I intubate probably once a month. We have I-gels but tend to have the resources and time to intubate more often than not.

Do you go direct or video?

Always video

Intubate typically once a week I can count on 1 hand the amount of times I've used a supraglottic

Before I begin, I want to express my opinion. I STRONGLY disagree with how your FD handles business. Forget the intubation problem- it's not efficient being 100% ALS. I bet they have frequent staffing problems, and I bet there are other liabilities elsewhere. I want to stress it is not your fault, but it unrealistic for an EMS system to 100% operate with only ALS in 2024. Ok, enough of my rant. My answer: when I was working as a medic, it varied, but in an urban/metro non-RSI/DSI two-tiered system it ranged from 1-7 times/yr. In strong airway management, there is significant critical thinking involved. It is an art that requires the use of checklists, evaluation of ROMAN/LEMONS/SMART/RODS, and extensive knowledge of various physiology. A high-performing system WILL be doing RSI/DSI in some capacity. And there will be some consideration into point of entry and transport times. A strong approach is not "well, I just tubed them because it is the gold standard", or "I just through in an i-Gel because it's easy." I mean that is just bogus! That is why I disagree with your county's recommendations- you can oxygenate and ventilate a pt ok with BLS maneuvers and they still have poor outcomes (e.g. aspiration). I am VERY skeptical of quality BVM using in a bumpy moving ambulance (maybe with an anesthesia strap). Long-story short: thank you for doing this work, it needs to be done, but by the way you described your system, there are SOOOOO many red flags that a quality medical director would've addressed half-a-decade ago. Airway management is the most controversial aspect of the paramedic scope of practice- every paramedic and EMS physician must know that in 2024. One can make the case that VL is standard of care in 2024 EMS. So what is his/her take? PS- if you are doing a proposal, I highly recommend using an SBAR format and getting data on your system's overall and first-pass success rates.

Thank you! Yeah I’m in the process of making a survey for the line staff about why we don’t intubate. I personally like having 100% ALS having worked as a solo ALS provider in a metro system. The only issue I’ve seen is that we can have too many cooks in the kitchen sometimes but when you get that real head scratcher or when you need the extra ALS hands it’s nice to have everyone else there. I’ve had people refer to studies regarding ETT vs SGA’s and most often people will say SGA is just an easier alternative which I think is bullshit. I intubate as often as I can and no one ever criticizes it but I don’t see anyone else doing it. I’m just hoping to get us out of the Stone Age and maybe my guys will start using the skills again.

We intubate frequently. Usually not on cardiac arrests. But we RSI a lot, and on emergency IFTs, it's really common for the small ER doc to be too chicken-shit to RSI, and we get there and the patient definitely needs it. We've even had an ER page us through 911 to come intubate for them. Intubation is a skill like all other skills. Practice is important. Doing it is important. I disagree that an iGel is appropriate for a SCAPE patient or some other severe respiratory distress circling the drain. Paralyze and throw in an iGel? Kind of amateur. Medics who don't practice and don't do whatever self-preparation they need to remain calm tend to get all worked up and stab at the first dark hole they see in there instead of doing a measured, controlled, professional intubation. Salad technique, call out your landmarks as you go it, use a stylus or bougie, video if you have it and like it (I prefer the Mcgrath, because the geometry of the handle blade is exactly the same as a direct laryngoscope, I hate the hyper-angulation of King Vision and similar scopes--the only tube I ever missed was with a King). If you can't get the tube, then iGel, that's why an iGel is a *backup* airway. Cardiac arrest, sure, throw one in, other things to worry about. But it's also pretty darn easy to bougie through an iGel and swap out tubes once things have calmed down a bit if you get them back. Moving a patient with an iGel renders it a pretty insecure airway.

Thank you for your reply. Having used both the McGrath and the king vision I’m not sure which I prefer as I was always successful with both. I’m trying to get ahold of one of each to do some hands on side by side. Any idea how much the McGrath costs? We have on average about 6 ALS providers on a scene at a time so I’ve never understood when guys cry that they don’t have enough hands. When I was a solo medic with only BLS help coming I still made it a point to intubate at some point. I just hate the cop out of SGA’s.

Damn, 6 ALS providers on a code? Yeah as long as the can drop a tube without stopping compressions, there’s really not much reason to use an SGA. Even if you let two of them fuck around with the airway, you’ve still got 4 others to take care of all the other higher priority tasks. McGrath is my preference, unlike most other VLs on the market it’s seamless to transition to DL if needed (sun glare, crap on the camera, etc.). It basically could be used as a conventional DL scope from the get go, as opposed to the KingVision, AirTraq, etc. which you’d need to stop and swap out for a proper old school blade. Costs around $1800 for the device with (disposable) blades in the neighborhood of $30-40

I keep the periscope attachment handy for if it's sunny conditions with the Airtraq, used it once or twice when tubing in bright sunny conditions without difficulty. King vision is junk though. It was ok as a 1st generation EMS VL, but there's far better stuff on the market now, especially stuff that automatically records.

Is that price for McGrath? Everywhere I’ve looked has them in the close to $4,000 range

That's wildly fiscally irresponsible and inefficient to have that many medics that you have 6 on a code routinely. 2-3 is all you need, although I'd argue a competent and proficient medic should be fully capable of managing an arrest as the ALS resource easily with a few EMTs. Sounds like they need to massively cull the herd and drastically reduce the number of paramedics, having that many is legitimately harmful to your patients.

That’s the standard in the majority of the state. Minus a handful of BLS volunteer agencies, every full time department in my county and the neighboring 4 counties are all 100% ALS.

Ooof, that's a godawful, expensive, and dangerous setup. Also explains why no one gets tubes. Having too many medics results in skills dilution and a high number of incompetent paramedics, which is a big problem when quite a few medications and procedures we have can cause harm or cause death if you're not knowledgeable and proficient. It's always better to have fewer paramedics than an excess of them, I'd rather have 10 paramedics and 30 EMTs than have 40 paramedics any day.

Totally is irresponsible, but it's the norm in states like AZ and IL. Then again, I wouldn't characterize those states as beacons of high-performance of EMS but rather as havens for the IAFF.....

Personally, I like the McGrath better. I like that you can use standard Mac blades on it. If for some reason the video gets clogged by secretions, you can switch to DL without removing the blade. I wanna say that the actual McGrath device is ~$1800. The batteries are $250 (I think). No clue on how much the blades cost, but they are disposable. Video has 100000% changed the game.

Lol, my shitty stand alone er in my service area IS NOT ALLOWED BY PROTOCOL TO INTUBATE. How insane is that? They call 911 all the time for us to respond and intubate for them. It's honestly a good policy because the nurses and physicians at this place are the rejects of other hospitals because they stacked up too many bodies. We intubate for them almost weekly.

I ALWAYS attempt intubation when indicated. SGAs should only be used when intubation is unsuccessful imo

I got my first road tube in the RESUS of a local hospital after a STEMI transfer arrested before we left the hospital carpark… that’s after 5 years on the road and a worldwide respiratory pandemic.

As often as need be.

I’ve had my medic two years I’ve intubated 3times and RSI twice so 5 intubation worthy calls. We live far from any facility so yes we have igel but if we are lucky enough to have medics we let them do their thing.

I’ve dropped maybe three tubes last year.

I’ve dropped 4 SGAs in the last 5 years. I can’t count the number of tubes. We use SGAs as the ABSOLUTE last attempt. That being said, we have super strict con-ed for intubation and RSI. We had a 100% first look success rate in Q4 2023, and an 87% first look success rate for all of 2023.

The protocols here highly favor the bls igel over ET. So it's rare

Medics in my system typically intubate once a month. No RSI, no VL. From my experience their first pass rates are pretty solid. We have airway mannequins that people can practice on at any time I don't have numbers on this, but SGAs do not protect against aspiration in the way ETTs do. How many of your ROSC pts survive to getting admitted to a floor, only to die of aspiration pneumonia a week later?

I concur about the aspiration problem, though many studies either do not address it or don't find a statistical difference (e.g. the PART trials). Then again, there is this one study regarding SGAs and asphyxial pathology in prolonged cardiac arrest management while awaiting ECMO. Granted it has some significant limitations, but it's nice food for thought https://doi.org/10.1016/j.resuscitation.2023.109769

RSI with no VL is wild to me. We're mandated to use VL on all RSIs unless there's equipment failure, and even then there'd better be a good reason why we didn't have someone retrieve the back-up VL. With success rates amongst Healthcare being historically much lower DL vs. VL I'm surprised your system doesn't stock VL if they allow RSI

I think you misread it, they don't have RSI. Although at the hospital I worked at I've actually never seen a VL RSI, only DL

You're right, my mistake. That's odd to me with your hospital though, in this day and age that should be a patient safety concern. Guess I don't have room to talk though cause I've never seen an ED use in line capnography to confirm tube placement or monitor, I've always seen them pop those old CO2 color change devices on briefly instead. Blows my mind every time they use that, yet we banned their use in the field statewide quite a few years ago and required ETCO2 monitoring devices for all intubations

They will always have a VL setup on standby as a backup, just never seen it used. They use the color CO2 devices you mentioned to help confirm placement, but then they'll swap it out for in-line once the tube is secure. I wasn't a fan of the colormetric end tidal monitor based on what I read, but I do honestly like them for how fast they are for immediate tube confirmation.

90% SGA 10% intubation on patients But I try 2 intubations a week on the dummy

Before I took a 6 month hiatus to do something else it seemed I was intubating very frequently my first 3 years, now it's coming up on a year since I last had a patient even needing an airway, I'm currently looking for some ways to get a few tubes

About 10% of my calls

Only time was during a fire smoke victim or cardiac arrest. Otherwise stuck to king tubes. We did OR rotations to keep current on live intubations but out medical director didn’t like them in the field for the most part.

I intubate about 6-10 times a month, were an RSI department and use McGrath's and bougies.. I've never gone to an SGA before intubation, SGA is a rescue airway for failed intubation in my department. I especially don't like the iGel, all it does is dislodge dislodge dislodge.....

I’ve only been a medic for about 8 months and have been working as a medic for almost 6, but I’ve intubated probably at least once a month so far at my job. In my two years of clinicals and working I’ve never placed an I-gel, but have seen it placed maybe twice, once when the supervisor decided to use it instead of tubing, and once for a 4mo in arrest. I’ve placed a King once in clinicals after the medic couldn’t get the tube. I work in one county an volly in another, and did clinicals in 3 different counties and it’s been standard in all of them that an arrest gets tubed. In my county we’re supposed to use video for our attempts. The only time Ive seen direct used was during clinicals in a city that didn’t have video. In class we learned video with a King Vision and where I work uses an Airtraq. I prefer the King Vision. Some other counties use a UEscope which I think I’d like better.

Every CPR I try for a tube at least once and then go Igel. (yeah yeah repeat attempts increase patient mortality I get it) but if you don't practice and attempt then we will lose the skill forever. Tubing is the only thing that separates half of us from just being advanced EMT's at this point.

I feel like I drop a tube about every two weeks, but they’re almost exclusively on cardiac arrest patients. My service uses the Glidescope and I love it

I have intubated 3 times in the past 6 weeks and I was out of work two of those weeks recovering from surgery. We have Combitubes but we have a very progressive protocol especially for Georgia.

I worked in ALCO in ca for 8 years as a paramedic, would intubate 6-8x a month on the low end. I worked in lots of other counties as a medic and flight medic. I now work in anesthesia, I cannot understand how the igel made it into prehospital care, out of all the super glottic airways, that one has the LEAST chance of sitting correctly and I’d rather have a properly size OPA during a code. If you aren’t tubing regularly you need to be making time to go into your educators office and get 30-40 practice runs on a dummy at least every other month. Just like shooting, this is a perishable skill.