A is for airway

in EMS
What is controversy?
How to choose a topic?
Risk vs. Frequency
Low risk / Infrequent
High risk / Infrequent
Low risk / Frequent
High risk / Frequent
What are the biggest
controversies in EMS today?
Three questions
Three controversies
Three different styles of answer
The three for today
• Intubation
– High risk / Infrequent
• Analgesia administration
– Low risk / Frequent (At least it should be...)
• Lights and siren use
– High risk / Frequent
A is for…
We could do it…
• Jacobs LM, Berrizbeitia LD, Bennett B, et al. Endotracheal
• intubation in the prehospital phase of emergency medical care.
• JAMA. 1983;250:2175-2177.
• Stewart RD, Paris PM, Winter PM, et al. Field endotracheal
• intubation by paramedical personnel: success rates and
• complications. Chest. 1984;85:341-345.
• DeLeo BC. Endotracheal intubation by rescue squad personnel.
• Heart Lung. 1977;6:851-854.
• Guss DA, Posluszny M. Paramedic orotracheal intubation: a
• feasibility study. Am J Emerg Med. 1984;2:399-401.
Can we still?
• 25% misplaced
Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics
in an urban emergency medical services system. Ann Emerg
Med. 2001;37:32-37.
• 12% misplaced
Jemmett ME, Kendal KM, Fourre MW, et al. Unrecognized
misplacement of endotracheal tubes in a mixed urban to
rural emergency medical services setting. Acad Emerg
Med. 2003;10: 961-965.
What can help us do it right?
• Waveform capnography
– 23% misplaced
when not used
– 0% when used
Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out-of hospital
use of continuous end-tidal carbon dioxide monitoring
on the rate of unrecognized misplaced intubation within a
regional emergency medical services system. Ann Emerg Med.
What about outcomes?
• 830 pediatric patients
• Prospective trial
• No outcome advantage from ETI
Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital
pediatric endotracheal intubation on survival and neurological
outcome: a controlled clinical trial. JAMA. 2000;283:783-790.
San Diego
Ochs M, Davis D, Hoyt D, et al. Paramedic-performed rapid
sequence intubation of patients with severe head injuries. Ann
Emerg Med. 2002;40:159-167.
Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid
sequence intubation on outcome in patients with severe
traumatic brain injury. J Trauma. 2003;54:444-453.
Davis DP, Peay J, Sise MJ, et al. The impact of prehospital
endotracheal intubation on outcome in moderate to severe
traumatic brain injury. J Trauma. 2005;58:933-939.
Dunford JV, Davis DP, Ochs M, et al. Incidence of transient
hypoxia and pulse rate reactivity during paramedic rapid
sequence intubation. Ann Emerg Med. 2003;42:721-728.
Davis DP, Valentine C, Ochs M, et al. The Combitube as a
salvage airway device for paramedic rapid sequence intubation.
Ann Emerg Med. 2003;42:697-704.
The review and the rebuttal…
“Out-of-hospital endotracheal intubation may
inadvertently interact with other key physiologic
processes key to optimizing resuscitation…”
‘Resounding thunderclaps in a storm of debate
about out-of-hospital endotracheal intubation ’
Wang HE, Yealy DM, Out of hospital endotracheal intubation: Where are
we? Annals of EM 2006;47:6, 532-542
Burton JH, Out of hospital endotracheal intubation: Half empty or half full?
Annals of EM 2006;47:6, 542-4
What we know…
• Hypoxia increases mortality and morbidity
• Hypocarbia increases mortality and
• Paramedics interpret airway interventions
differently than physicians
• Waveform capnography is the gold
standard in LIVE patients
• Few misplaced endotracheal tubes reported
• Recent survey: (non-scientific)
– People who took airway course: >80% success
• Average number of intubations: 5
– People who did not: <70%
• Average number of intubations: 1/2
– Most providers do not intubate each year
Answers we still need…
• What about medical patients?
• Is outcome better with a combitube or LMA?
• How will we train paramedics to intubate as
ACLS de-emphasizes intubation?
• Should paramedics intubate?
College Position Papers
• American College of Emergency
• American Academy of Pediatrics
• American Medical Association
• American College of OB and Gyn
• American College of Surgeons
NAEMSP Position Paper
Mandatory pain assessment
Indications for pain management
Alternatives for pain management
Patient monitoring
Transfer of patient information
Quality improvement and medical
Why is pain undertreated?
5. Lack of medical training
4. Misunderstandings about addiction
3. Lack of routine assessment
2. Misunderstanding about adverse events
1. Fear of regulatory oversight
New York Stories
Time Frames
• Mean time to medication:
• Range:
24 minutes
3-61 minutes
• Females, mean:
• Males, mean:
25.6 minutes
23 minutes
• Precedent for standing order treatment for seizures
with controlled substances
• No history of diversions in REMO
• Protocol and systems review by NYS DOH Bureau of
Narcotics Enforcement and Bureau of EMS
“We don’t want our concerns about a few diversions to
stand between your patients and pain management.”
Jim Giglio, Director, Narcotics Enforcement
What is the right agent?
• A medication with a rapid onset of action
– Easily titrated to effect
• A medication with a short half-life
– Rapidly metabolized for “exam in ED”
• A medication that is easily dosed
– 1 ‘unit’ per kilogram
Galinski M.
A randomized, double-blind study comparing
morphine with fentanyl in prehospital analgesia.
Am J Emerg Med. 2005 Mar;23(2):114-9.
National trends
• 14 States require physician contact for
administration of narcotics
• 37 States allow STANDING ORDER pain
management administration
• 16 States allow the use of Fentanyl for
pain management; all on STANDING
(For extremity fractures and burns)
Lights and sirens
[Please note that editing has been
done to abstracts presented to allow
for space. Intent and content have
not been altered]
Is ambulance transport time with lights
and siren faster?
• OBJECTIVE: To determine whether ambulance transport time from
the scene to the emergency department is faster with warning lights
and siren than that without.
• DESIGN: In a convenience sample, transport times and routes of
ambulances using lights and sirens were recorded by an observer.
The time also was recorded by a paramedic who drove an
ambulance without lights and siren over identical routes during
simulated transports at the same time of day and on the same day
of the week as the corresponding lights-and-siren transport.
RC Hunt, LH Brown et al. Ann Emerg Med 1995 Jun;25(6):857
Is ambulance transport time with lights
and siren faster?
• SETTING: An emergency medical service system in a city with a
population of 46,000.
• RESULTS: Fifty transport times with lights and siren averaged 43.5
seconds faster without lights and siren [t = 4.21, P = .0001].
• CONCLUSION: In this setting, the 43.5-second mean time savings
does not warrant the use of lights and siren during ambulance
transport, except in rare situations or clinical circumstances.
RC Hunt, LH Brown et al. Ann Emerg Med 1995 Jun;25(6):857
Do Warning Lights And Sirens Reduce
Ambulance Response Times?
• OBJECTIVE: To determine the time saving associated with lights
and siren (L&S) use during emergency response in an urban EMS
• METHODS: This study evaluated response times to the scene of an
emergency in an urban area...At a later date, ‘they’ retraced the
route--at the same time of day on the same day of the week--without
using L&S and recorded the travel time.
LH Brown, RC Hunt, et al, Prehospital Emergency Care 2000 January-March 4:1;70 - 74
Do Warning Lights And Sirens Reduce
Ambulance Response Times?
• RESULTS: The 32 responses with L&S averaged 105.8 seconds (1
minute, 46 seconds) faster than those without (95% confidence
interval: 60.2 to 151.5 seconds, p = 0.0001). The time difference
ranged from 425 seconds (7 minutes, 5 seconds) faster with L&S to
210 seconds (3 minutes, 30 seconds) slower with L&S.
• CONCLUSION: In this urban EMS system, L&S reduce ambulance
response times by an average of 1 minute, 46 seconds. Although
statistically significant, this time saving is likely to be clinically
relevant in only a very few cases. A large-scale multicenter L&S trial
may help address this issue on a national level.
LH Brown, RC Hunt, et al, Prehospital Emergency Care 2000 January-March 4:1;70 - 74
Time saved with the use of lights and
siren in a rural environment
• OBJECTIVE: To determine whether the use of warning lights and
siren saves a significant amount of time for ambulances responding
to requests for emergency medical aid in a rural emergency medical
services (EMS) setting.
• METHODS: A prospective design was used to determine run times
for ambulances responding to calls with lights and siren (code 3)
and for a similarly equipped "chase" ambulance traveling to the
same destination via the same route without lights and siren, while
obeying all traffic laws (code 2) within a rural setting. Data were
collected for run time intervals, distance traveled, visibility, road
surface conditions, time of day, and day of the week.
J Ho, M Lindquist, Prehosp Emerg Care. 2001 Apr-Jun;5(2):159-62
Time saved with the use of lights and
siren in a rural environment
• RESULTS: Sixty-seven runs were timed during a 21-month period.
The average code 3 response interval was 8.51 minutes. The
average code 2 response interval was 12.14 minutes. The 3.63
minutes saved on average represents significant time savings of
30.9% (p < 0.01). Shorter runs had higher time savings per mile than
the longer runs. Run distance was the only variable that was
statistically significant in affecting time saved during a code 3
• CONCLUSION: Code 3 operation by EMS personnel in a rural EMS
setting saved significant time over code 2 operation when traveling
to a call.
J Ho, M Lindquist, Prehosp Emerg Care. 2001 Apr-Jun;5(2):159-62
Emergency medical vehicle collisions in
an urban system
• INTRODUCTION: Emergency medical services collisions (EMVCs)
are a largely unexplored area of emergency medical services (EMS)
research. Factors that might contribute to an EMVC are numerous
and include use of warning lights and siren (WL&S).
• METHODS: Retrospective study of all collisions involving vehicles
assigned to the EMS Division of the Houston Fire Department in
calendar year 1993. Fifty-one ambulances were operational 24
hours per day during calendar year 1993. Houston EMS received
150,000 requests for assistance, made 180,000 vehicular
responses, and accrued 2,651,760 miles in 1993.
WA Biggers Jr, BS Zachariah,et al, Prehospital Disaster Med. 1996 JulSep;11(3):195-201
Emergency medical vehicle collisions in
an urban system
RESULTS: Eighty-six EMVCs were identified during the study period. The
gross incidence rate was therefore 3.2 EMVC/100,000 miles driven or 4.8
collisions/10,000 responses. Major collisions, determined according to
injuries or vehicular damage, accounted for 10.8% of all EMVCs. There
were 17 persons transported to hospitals from EMS collisions, yielding an
injury incidence of 0.64 injuries/100,000 miles driven or 0.94 injuries/10,000
responses. There were no fatalities. The majority of collisions (85.1%)
occurred at some site other than an intersection. Drivers with a history of
previous EMVCs were involved in 33% of all collisions. The presence of
prior EMVCs was associated (p < 0.001) with the number of persons
transported from the collision to a local hospital. Five drivers, all with
previous EMVCs, accounted for 88.2% (15/17) of all injuries.
CONCLUSIONS: A few drivers with previous EMVCs account for a
disproportionate number of EMVCs and nearly 90% of all injuries. This risk
factor--history of previous EMVC--has not been reported in the EMS
literature. It is postulated that this factor ultimately will prove to be the major
determinant of EMVCs. Data collection of EMS collisions needs to be
standardized and a proposed collection tool is provided.
WA Biggers Jr, BS Zachariah,et al, Prehospital Disaster Med. 1996 JulSep;11(3):195-201
The wake-effect--emergency vehiclerelated collisions.
• INTRODUCTION: Experience suggests "wake-effect" collisions
occur as a result of an EMS vehicle's transit, but do not involve the
emergency medical vehicle (EMV). Substantiating the existence and
magnitude of wake-effect collisions may have major implications
regarding the manner of EMV response.
• METHODS: Survey analysis. Participants: Thirty paramedics
employed by the Salt Lake City (Utah) Fire Department and 45
paramedics employed by Salt Lake County Fire Department. The
survey consisted of three open-ended questions concerning years
on the job, EMVCs, and wake-effect collisions.
JJ Clawson, RL Martin, et al, Prehospital Disaster Med. 1997 Oct-Dec;12(4):274-7.
The wake-effect--emergency vehiclerelated collisions.
• RESULTS: Seventy-three surveys were analyzed. Sixty EMVCs and
255 wake-effect collisions were reported. Overall, the mean value
for the number EMVCs per respondent was 0.82 (0.60-1.05) and for
wake-effect collisions 3.49 (2.42-4.55). The mean values for EMVC's
for each service were 0.86 (0.50-1.38); 0.80 (0.50-11.0). For wakeeffect collisions the mean values were 4.59 (2.83-6.35); and 2.76
(1.46-4.06) respectively.
• CONCLUSIONS: This study suggests that the wake-effect collision
is real and may occur with greater frequency than do EMVCs.
Significant limitations of this study are recall bias and
misclassification bias. Future studies are needed to define more
precisely wake-effect collision prevalence and the resulting "cost" in
regards to injury and vehicle/property damage.
JJ Clawson, RL Martin, et al, Prehospital Disaster Med. 1997 Oct-Dec;12(4):274-7.
The effectiveness of lights and siren use
during ambulance transport by paramedics
• OBJECTIVES: To determine whether lights and siren (L&S) use
during transport in the authors' EMS system results in reduced
transport time to the hospital. Second, to determine whether L&S
use results in any emergency department critical interventions in the
time saved.
• METHOD: A convenience sample of transport times were measured
for 75 ambulances traveling to the hospital with L&S and compared
with measured simultaneous transport times for a personal observer
vehicle traveling the same route as the ambulance. Upon hospital
arrival, the driver of the observer vehicle proceeded to the patients'
locations and noted the medical interventions accomplished at the
hospital prior to his arrival. Interventions were reviewed to identify
time-critical interventions that would have been delayed without L&S
DJ O’Brien, TG Price, et al. Prehosp Emerg Care. 1999 Apr Jun;3(2):127-30
The effectiveness of lights and siren use
during ambulance transport by paramedics
• RESULTS: The mean ambulance transit time was 666 seconds and
the mean observer transit time was 896 seconds. The mean
difference in ambulance (L&S) transit time and the observer (no
L&S) transit time was 230 seconds (3 min, 50 sec). There was a
statistically significant correlation between transit time difference and
number of stoplights encountered, traffic intensity, and distance
traveled. Of the 75 patients transported, four patients were felt to
have benefited clinically by the time saved.
• CONCLUSIONS: Use of L&S significantly shortens transport time. In
this series of patients transported under the care of a paramedic, the
time saved by the use of L&S was not usually associated with
immediately apparent clinical significance.
DJ O’Brien, TG Price, et al. Prehosp Emerg Care. 1999 Apr Jun;3(2):127-30
Patient outcome using medical protocol
to limit "lights and siren" transport.
• INTRODUCTION: Emergency medical services vehicle collisions
(EMVCs) associated with the use of warning "lights and siren" (L&S)
are responsible for injuries and death to emergency medical
services (EMS) personnel and patients. This study examines patient
outcome when medical protocol directs L&S transport.
• DESIGN: During four months, all EMS calls initiated as an
emergency request for service and culminating in transport to an
emergency department (ED) were included. Medical criteria
determined emergent (L&S) versus non-emergent transport.
Patients with worsened conditions, as reported by EMS providers,
were reviewed.
DF Kupas, DJ Dula, et l, Prehospital Disaster Med. 1994 Oct-Dec;9(4):226-9.
The effectiveness of lights and siren use
during ambulance transport by paramedics
• RESULTS: Ninety-two percent (1,495 of 1,625) of patients were
transported non-emergently. Thirteen (1%) of these were reported to
have worsened during transport, and none of them suffered any
worsened outcome related to the non-L&S transport.
• CONCLUSION: This medical protocol directing the use of warning
L&S during patient transport results in infrequent L&S transport. In
this study, no adverse outcomes were found related to non-L&S
DF Kupas, DJ Dula, et l, Prehospital Disaster Med. 1994 Oct-Dec;9(4):226-9.
Take home message
• EMS is a key intersection between public safety and
public health
• EMS is dynamic and we must study outcomes to
determine appropriate protocols
• We must demand system development and access to
information so that EMS outcomes can be measured
• Physicians must drive the development of protocols for
EMS that balance public and provider safety
• “Because we always have,” should never be the answer
Thank you.
Additional references
Thanks to:
• Kate Nelson
• David Neubert
• Dan Gerard