Guest Editorial: Ego-tracheal Intubation?

Endotracheal intubation has become the defining skill of paramedics. It sets us distinctly apart from basic life support providers and nurses in the ED, and it puts us on a collegial level with emergency department physicians. There is hardly anything more satisfying than the placement of a good tube. It can be a big ego boost. 

However, this focus can cause some ethical dilemmas. Are we intubating patients who could be better managed to prevent the need for an ETT? Do we sometimes think of patients as opportunities to intubate?

This problem is not limited to paramedics. We’ve all seen ED physicians struggle to place ETTs for too long without asking for help. Nurses may refer to patients in terms of their injury or illness: “the GI bleed in Room 4.” Have you ever heard an EMS provider say, “I could go for a good trauma call today!”?

For thousands of years mankind has struggled to restore the breathing of those who have stopped. Tracheotomies were used long before the thought of placing a tube in the airway was discovered. Ancient Egyptian and Greek texts document tracheotomy techniques including using the tip of a sword to make the incision on the battlefield.¹ 

We’ve come a long way in technology and skill. Video laryngoscopes use a camera and monitor to visualize the airway as the tube is placed. The video scopes now found on most paramedic units represent a further advance.

We still contend, though, with the old problem of ego preventing the use of this new tool. Research has shown us that video laryngocopes improve first-pass endotracheal intubation success.² Yet I’ve spoken with several paramedics who say they are afraid of losing their manual laryngoscope skills. They don’t want to be seduced into using the video scope. They’ll use it only on difficult airways, when they’ve failed on their initial attempt with a direct laryngoscope. They proudly tout that they are completely confident in their manual laryngoscope skills. To me this is like preferring a rotary phone to a smartphone. 

What is truly the defining skill most important to a paramedic? Endotracheal intubation? IV or chest decompression skills? Everyone in EMS must know that they are more than just a set of clinical skills. The best part of any clinician is being human. 

Practicing compassion is as important as practicing clinical skills. One of the best resources for this subject is the 2019 book Compassionomics by Stephen Trzeciak and Anthony Mazzarelli. Research shows your intentions and the words you speak enhance all the clinical skills you administer. 

Endotracheal intubation is a defining and lifesaving skill for paramedics. Thank goodness not all patients need to be intubated and not all EMS calls are severe traumas, difficult airways, or cardiac arrests. 

Letting go of ego brings a clearer focus to patients’ needs. Getting a good tube or a difficult IV will always be a proud event, but making compassion a standard practice will bring you the most long-term fulfillment in your work. Even those simple calls that require no complex care are a great opportunity to practice compassion. They can be the most rewarding. 

References

1. Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med, 2008; 34: 222–8. 

2. Suzuki K, Kusunoki S, Tanigawa K, Shime N. Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study. BMJ Open, 2019; 9:3. 

Jaime V. Pitner, MSN, RN, MICP, CEN, RHC, began his career as a paramedic in New Jersey and has served as director of the MICU for Burlington County,  assistant chief of EMS and SCTU in Atlantic and Cape May counties, president of the MICU Paramedic Association, and first chair of the New Jersey State EMS Council. He has been an ED director and nurse educator for the largest hospital systems in New Jersey.