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Video Laryngoscopy's Place in an Ambulance

Paramedics might have to adapt what they hear during formal intubation training. (Photo JEMS)

By A.J. Heightman, MPA, EMT-P

I remember gowning up early in the morning and meeting with the assigned anesthesiologist to go over the OR schedule and being told whom I could and couldn’t intubate. If the patient had a jutting jaw, a large neck, a history of cervical fracture or poor teeth, I wasn’t allowed to intubate them and was required to just watch the anesthesiologist manage these “difficult” patients.

The funny thing is that many of the patients I was later called on to intubate in the street met one or more of those exclusionary criteria.

Over time, anesthesiologists have become less willing to expose themselves to liability by allowing paramedic students to intubate patients they were contracted to manage. Therefore, many of today’s paramedics never intubated a live patient prior to being turned loose to intubate in the prehospital arena. That’s a frightening thought.

Laryngoscopy, as we’ve traditionally known it, is also being re-evaluated and reprioritized in protocols by EMS medical directors. The change comes in light of studies showing that all paramedics are not equally proficient at the skill, and because the emphasis in cardiac arrest resuscitation is now more directed at continuous and consistent compressions in the early stages of resuscitation than airway management by intubation.

The increasing number of paramedics deployed on fire apparatus and ambulances is also resulting in fewer opportunities in many EMS systems to place endotracheal tubes, with some placing only one or two tubes annually. This is presenting new challenges to medical directors and service training staff because they must more frequently review and refresh paramedics on this critical skill. This also increases service and municipality exposure to liability for misplaced endo­tracheal tubes by their paramedics.

Further, the current demand on hospitals to report and reduce medical errors has a significant ripple effect on prehospital providers transporting intubated patients to emergency departments (EDs), with more hospital scrutiny of prehospital airway care than ever before.

What this all means is that fewer ET tubes will be placed in many EMS systems, those that are placed will have to be accomplished with little or no interruption in compressions, and each tube will be carefully evaluated on arrival at an ED.

Placing an ET tube with standard eye-to-vocal cord visualization during compressions, in a moving ambulance, and in the tight confines and configurations presented in helicopters, is a difficult task that’s prompting hospitals, ground EMS systems and aeromedical programs to consider video laryngoscopy.

What started out as a creative training aid by innovators like Richard Levitan, MD, allowing students to observe the anatomy of patients and the process of intubation through video imaging, has evolved. It’s now refined and incorporated into compact video laryngoscopes, such as the Verathon® GlideScope® Ranger, which shows you an image on its screen that’s twice the actual anatomical size.

The clarity and utility of the video laryngoscope are so good that anesthesiologists, ED physicians and flight crews are using them on a regular basis. This trend has direct ramifications on the prehospital performance of intubation because, as in-hospital airway management processes and equipment changes, so too will prehospital processes and equipment.

The supplement to JEMS “The Perfect View” presents the advent of the device and how EMS systems are using the tool so you can understand the technology and its potential impact on you and your service in the future.


  1. Anesthesiologists, ED physicians and flight crews know how to intubate and have performed many intubations to where they are just adding another tool for the difficult airways or in the case of a flight crew, a better view in a limited space.

    I can see the video laryngoscope becoming even more of a reason for Paramedic school to gloss over intubation. If you are not extremely proficent at intubation without video assistance, you should not be intubating regardless of the method. This should not be a substitute for eduacation and training.

  2. Dr John Pacey MD FRCSc

    Hello JS
    There is evidence in the literature that video laryngoscopy assists in teaching DL skills. It seems clear to me that when EMS treats a patient they have a duty to choose the best tools, learn how they are used and then apply them appropriately.
    Training is necessary but appropriate technology will enable higher performance. The mission is what we should focus on.
    Drs Wayne and Rothfield are in the process of showing that video laryngoscopy in EMS is superior to DL and especially when applied to intubation during “uninterrupted CPR” .

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