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Should EMS Intubate?

The Intubation Debate

Intubation is one of many tools in the EMS provider’s airway management toolbox. (Photo A.J. Heightman)

Did you make it to the 2011 EMS Today Conference & Exposition? What a great experience! I had the honor to moderate a panel discussion titled “Should We Intubate?” Four great panelists and about 200 folks in the audience resulted in lively debates and a challenge to be great EMS providers. As the moderator, I really didn’t get the chance to stand on my soapbox, so I’ll take that opportunity now.

Why does the thought of taking endotracheal intubation out of the hands of paramedics invoke such a visceral response? I didn’t whine when the EOA left. No heartburn when I put MAST back on the shelf. What is it about an ET tube? Because for decades, it’s all we had.

Endotracheal intubation via direct laryngoscopy has been used since the late 1800s.1 Numerous BLS airways were developed during World War II. Extraglottic airways appeared in our airway kits in the early 1980s.2 Flexible and rigid fiber optic laryngoscopes made their way into operating rooms in the early 1990s. It wasn’t until the turn of the century that laryngoscopy changed for EMS with the development of video laryngoscopes.

For about 110 years, direct laryngoscopy has been THE method to place an endotracheal tube. In EMS, we’ve relied on this method for about 40 years (depending on how you write the timeline). We reinforce the dogma that the endotracheal tube is the airway of choice by referring to all other devices as “rescue airways.”

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So I ask the question: Should we intubate? When it’s appropriate, absolutely. The endotracheal tube is a wonderful tool that has been successfully placed and managed for decades outside of the operating room. It continues to be used successfully by EMS professionals on a daily basis.

I’ve read a ream of studies professing the evils of prehospital endotracheal intubation. While there are descriptions of hypoxemia and trauma during endotracheal tube placement, the vast majority of the described evils come from what is done after the tube is placed; hyperventilation, hypocarbia, unrecognized misplaced tubes and reduction of blood return to central circulation.

Wait a minute; can’t those same evils occur with extraglottic airway devices or even a bag-valve mask? Why yes, they can. You can also add gastric distention, vomiting and reduced tidal volume to the BVM list. We have to do a great job managing any airway device.

As technology has progressed, we’ve been given fantastic new tools to help us do a better job. We’ve all seen studies that show the effectiveness of end-tidal carbon dioxide monitoring to verify tube placement and appropriately ventilate. Since 2003, studies from hospital and EMS settings have published results of the use of video laryngoscopy; shorter intubation times than direct laryngoscopy, high first pass success rates, and Grade I–II views with poor neck mobility.3-5 The gum elastic bougie, (and its plastic alternatives) is such a simple and incredibly effective tool, it should be mandatory in every airway kit. I’m quite sure you can list several other items. Proven technology must be embraced as the standard of care for our patients.

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So, I ask: Should you intubate? It’s entirely up to you. Are you willing to use the tool that best fits the patient, the conditions and your abilities? Are you willing to do what it takes to be a professional airway manager?

I’ll leave you with the challenge leveled at the end of the panel discussion. All of us must drive to excel as medical professionals, to refuse to accept mediocrity as a level of care and to simply do the very best for our patients.

I’m excited and humbled at the opportunity to provide information that will help all of us become better airway managers. I look forward to hearing from you.

Until next time, take care and be safe.



  1. Bailey B (1996). “Laryngoscopy and laryngoscopes–who’s first?: The forefathers/four fathers of laryngology.” The Laryngoscope. 106(8):939–943, 1996.
  2. Donmichael TA. US Patent 4497318, Feb. 5, 1985.
  3. Agro F, Barzoi G, Montecchia F. “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” Br J Anaesth. 90(5):705–706, 2003.
  4. Nouruzi-Sedeh P, Schumann M, Groeben H. “Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.” Anesthesiology. 110(1):32–37, 2009.
  5. Cormack RS & Lehane J. “Difficult tracheal intubation in obstetrics.” Anaesthesia 39(11):1105–1111, 1984.


EOA = Esophageal obturator airway

MAST = medical anti-shock trousers

BVM = bag-valve mask

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  1. This is an example of pure stupidity. Take tools away that saves lives. Don’t see any stats on successfull situations. HOW MANY PEOPLE ARE WALKING AROUND RIGHT NOW, that were intubated. We get new tools to do a better job in this area, and we practice on a continual basis.
    The drug industry makes better and greater drugs all the time. No matter what they do, some people can’t take them, or there are side effects. Should we remove drugs from medicine?

  2. Although I understand the concern and overall problems associated with intubation, in my 30+ years in EMS, and nearly all as a paramedic, I believe the real problem here is good initial and continued training in this skill. I’ve actually found that ETI is an easier skill than starting an IV in many cases when learned properly. How have we dealt with problems here? We’ve introduced IO to supplement this procedure in the field. We haven’t done away with it. Why? Because, it’s the golden standard – the preferable method of vascular access. Without getting into a long debate, ETI should remain the ultimate goal and golden standard of airway management. However, as we have been doing the last several years, we should always look for ways to improve what we do and have alternatives for those special cases where the preferable methods and means do not fit. Lets not fix something that isn’t necessarily broken. It may just need another approach and keep our choices broad. Don’t limit our choices here. The fix may also have it’s drawbacks at some time, and not everyone is a difficult airway. I’d bet that most are routine and simple.

  3. Perhaps there are city EMS services where medics get the opportunity to tube every day. In our rural area, our entire EMS service may have two or three opportunities a month to tube, and that has to be shared among more than a dozen medics. On the other hand, we all start IVs on every shift. As for continued training – Fred the Head is nothing like a real person. There’s no anatomical variation. Anesthesiologists use LMAs for many surgical procedures. I had an LMA myself for an appendectomy, and it was done in a university medical center. I’d rather use a King tube or LMA than fool around with an ET.

    • I agree that the King airway and LMA are great tools….As a rescue device. The problem with these two airways is the lack of protection provided to the airway in the event that the patient vomits; and the patient will vomit at some point. Anestehesiologists use these devices on patients that have been NPO for at least eight hours prior to arriving at the hospital for thier surgery. We do not have that luxury. That is why Endotracheal tube placement will always be the gold standard and should always be in the properly trained paramedics toolbox.

  4. Success at intubation as with success at any other endevor requiring skills and knowledge, is attained by practice. The more often we practice a process correctly, the more consistently we will be successful. Intubation should be a tool available to those dedicated enough to practice it as often as needed for them to become consistently successful at it. Control and protection of the patient’s airway can often mean the difference between life and death. All reasonable methods of achieving that control and protection should be available to the paramedic in the field. Direct layngoscopy, EGDs, BVMs, surgical and needle cricothyrotomy must be considered when the airway is at risk. There may be several reasons why one may be preferred over another and why some may be contraindicated. Paramedics require the training and the practice to make these decisions and execute the plan to protect the patient’s airway. We are certainly capable of doing this. Perhaps this is where we need to consider “Advanced Paramedics”?

  5. I beleive that intubation is an easy skill to learn. However, medics need to contually practive the skill i.e. in our neighbourhood hospital ORs

    The skill of intubation is required of course, it is the skill of when to intubate if paramount.

  6. I think all of the mentioned comments are hitting the nail on the head. Proper & frequent quality education/training is the key to our success. I too have had issues with the KingLT as it has allowed vomit to seep around the tube. But nevertheless I attend any airway courses available to me such as the SLAM course and our local EMS schools even offer airway sims courses too. It is our responsibility to do what it takes to keep fresh, current, and skillfull. People depend on us. Let’s not fail ourselves and our patients from not being properly prepared.

  7. This subject of pre hospital intubations now being in question as possibly ending greatly upsets me. This crucial skill needs to remain pre hospital. After all we are the ones who get the immediate need for it before anyone else don’t we? I have been ALS for 22 years now and I am hoping I have come up with possible solution to keep endotracheal intubations in the field. Please look into my new product called the Stylite, which is a safe and cost effective hopeful solution to rising esophageal tubes. This item self illuminates with a burst of super bright light from a chemiluminescent tip that bounces off the natural phosphorous of our vocal cords which marks the trachea. This product makes what is sometimes a difficult skill, easy enough where I have had 6, 7, and 8 year old children properly intubate the trachea of my manikin. From the thousands of people who have tubed my manikin with my Stylite at the expos, they all perform this skill in seconds in the dark. Endotracheal Intubation needs to remain in the field for rapid airway patency. I hope I can play a part in keeping ETIs in the field. Pat Ramos

  8. I too get tired of hearing this subject over and over. Let’s address the real problem of pre-hospital intubation. We have program where EMT’s go directly into paramedic school. These programs do not require a paramedic student to do any real intubations. These young or new medics are now finish school and start their careers. They have only completed their clinical on a manikin, really? Medical Directors allow these new medics to be cleared and start to work on a medic unit. They have never looked down the airway of a person, NEVER. I also believe in Capnography, this is why some studies state that the overall outcome is no better with field ETI. We now have the technology to main proper ETCO2 once our patients are intubated in the field. We have the tools to save our patients; maybe we need to use them. Are they no longer going to intubate in the ER, of course they will. Why you may ask, they use all the tools that they have to maintain proper ETCO2 as well as the proper training. Would an ER physician be allowed to intubate if he had never completed an intubation on anything but a manikin in school, of course not. It’s time for the Medical Directors, schools, EMS, Fire Departments and program directors to wake up. I still see this every day in program all across the country, someone please tell me why this still going on? There is no person in pre-hospital care that should be released without doing some OR time. Some may say we do not have a place to go and perform these as part of our programs. I am sorry to say that these programs MUST find a way to allow there student to perform intubation in a controlled environment. Also any Medical Director must mandate that all paramedics through someone’s program achieve this skill and be proficient at it. LETS ALL WAKE UP ! Also sorry if any typo’s, in a hurry but wish to leave a comment. BE SAFE ALL.

  9. While intubation seems to be a huge topic for descussion, what really bothers me & I can only assume the rest of prehospital medic’s, it that most of these judgements or reasonings for questions are falling off of a few tragic incidents. What we don’t hear are the circumstances behind the difficult intubation (i.e. traumatic airway, extrication complications, dangerous or hazardous situation.) or was it just an unskilled field provider. Most of the critics are never placed in the situations that we are as medic’s and if given that they were placed in the same situation, the question rises “How Well Would They Perform”. Intubation is a simple concept. Bottom Line, It is the most definative airway to provide a secure airway and every provide need to be a master of it. If additional training is needed for the providers that rarely gets the oportunity, then so be it. NO AIRWAY MEAN NO CHANCE for servival, becuase last I check HYPOXIA always WINS!

  10. Marvin Wayne, MD

    I think our success follows what most have noted. Excellent training and retraining, ETCO2 on all intubated patients, and new technology. I would suggest reading our article in PEC.

    Wayne, MA, McDonnell, MM, Comparison of Traditional vs. Video Laryngoscopy in Out of Hospital Tracheal Intubation, Prehospital Emergency Care, March 2010

  11. I believe that the push for the discontinuance of intubation in the field is driven by upper management throughout the U.S.. They do not want to spend the money that is necesary to continued training and QA/QI. That is the only reason that I see for this debate. I have been doing this for many years and I have personnel experience in what the field Paramedic is capable. I have watched ER Physicans spend an hour and a half trying to intubate a patient. Do you hear a scream for the ER to stop intubation. Most ER’s do not have an alternative airway device, other than doing a trach.
    So who is kidding who. If upper management wants it, it will happen.

  12. I would like to say that trying to decide whether to keep intubation in the protocols is a tricky thing to decide, but I would be lying because it isn’t at least not where I work. the system I work in is pretty busy and I’m likely to get a reasonable amount of practice, typically every medic on my unit will intubate between 1 and 3 times a month. Alot of the intubations we perform are on arrest situations where the value of the tube is really negotiable however the reason I don’t see this skill as negotiable is that out of all those intubations I’ve had at least 2 patients this past year that I can think of off the top of my head who without that tube would have been dead before we got to the hospital and as a direct result of being intubated, in the field, arrived to the hospital with a bounding pulse. I don’t think that either one of them would question the value of pre-hospital ETI’s.

  13. I would hate to see it taken out completely. Occasionally, there is and will be just that one time that nothing else will work or be appropriate. I don’t think we should be overdoing it just because we can. My philosophy has always been start basic and work up to whatever treatment the patient needs. That should be the same in airway management. If it is in our skill set, then it is up to us to keep current on the skill and the many ways to confirm it is being used properly.

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