Field Trial of Endotracheal Intubation by Basic EMTs,☆☆,,★★

Presented in part and judged Best Scientific Presentation at the Mid-Year Meeting of the National Association of EMS Physicians, San Diego, July 1995.
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Abstract

Study objective:The 1994 basic-EMT (EMT-B) curriculum recommended teaching EMT-Bs the skill of endotracheal intubation. In this study we assessed the success and complication rates of endotracheal intubations in the field by EMT-Bs. Methods: We conducted a prospective clinical trial over a period of 28 months in an urban out-of-hospital EMS system. Four first-responder EMT-B engine companies with paramedic backup received 10 hours' intubation training in three sessions spread over at least 2 weeks. The training module was similar to that of the 1994 EMT-B curriculum and included at least 10 intubations on manikins. The EMTs used manikins with closed chest cavities to learn assessment of endotracheal-tube placement. Patients were eligible for intubation by the EMTs if they were apneic and older than 15 years. We calculated 95% confidence interval (CIs) for intubation success rates. Results: Sixty-six EMT-Bs passed the training examinations and were authorized to perform intubation in the field. Endotracheal intubation was attempted by EMTs in 103 patients; the attempt was successful in 53 (95% CI, 42% to 61%). All patients who were not intubated by EMT-Bs were intubated by paramedics, with the exception of six cases. One attempt at intubation was made in 52 patients, two attempts in 44, and three in 7. Three unrecognized esophageal intubations occurred. Conclusion: EMT-Bs trained in a short course successfully intubated about half the patients they encountered in this study. This low intubation success rate calls into question the validity of the endotracheal-intubation training module in the 1994 EMT-B national curriculum. [Sayre MR, Sakles JC, Mistler AF, Evans JL, Kramer AT, Pancioli AM: Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med February 1998;31:228-233.]

Section snippets

INTRODUCTION

Early airway management is critical to the recovery of patients with life-threatening illnesses and injuries. Previous research has suggested that out-of-hospital endotracheal intubation improves survival after devastating conditions such as cardiac arrest and penetrating truncal trauma.1

In most areas of the United States, out-of-hospital endotracheal intubation is performed by paramedics and nurses. However, in many EMS systems, patients in respiratory or cardiac arrest are treated initially,

MATERIALS AND METHODS

We conducted a prospective clinical trial in the EMS system of the city of Cincinnati. The EMS program is based in the fire department and uses 35 fire companies staffed by EMT-Bs for first response. Four paramedic-staffed fire companies are used for first response in outlying areas. ALS and transport are provided by four second-tier paramedic-staffed ambulances. Patients with less serious illnesses or injuries are transported by six ambulances staffed by EMT-Bs.

We identified four fire stations

RESULTS

Sixty-six EMT-Bs completed the training program and passed the final examinations. Fourteen (18%) completed the examinations successfully on a second try. Ten additional EMT-Bs (13%) did not successfully complete the program. One did not pass the final written examination, and nine did not successfully complete the practical examination. Patient enrollment began on May 10, 1994, and was completed on February 28, 1997. More than 219 cardiac-arrest patients were cared for by EMT-Bs from the

DISCUSSION

Our findings demonstrate that most EMT-Bs could learn to intubate manikins after a very short training course. Unfortunately, this success in the classroom did not translate to a high success rate among patients in the field. Experienced emergency physicians are able to successfully intubate about 99% of patients.7 Most studies of paramedic field intubation show success rates better than 90%8, 9, 10, 11, 12.Therefore the success rate in this study of 51% is a cause for great concern.

In

Acknowledgements

We thank the many diligent EMT-B/firefighters in the Cincinnati Fire Division who attended the training sessions, worked hard to pass the examinations, and were willing to try a new procedure in the most difficult of circumstances. We also thank the paramedics who assisted in the training sessions and provided guidance in the field. We particularly thank Lt. Robert Baioni and Assistant Chief Gary Auffart. Without their hard work, this study would not have been completed. Finally we appreciate

References (16)

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    Intubation success rates correlate with the TI experience attained by individual paramedics.263 The high failure rate of 51% documented in the PART trial240 is similar to those documented in some prehospital systems more than 20 years ago.264,265 Tracheal intubation is a difficult skill to acquire and maintain.

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From the Department of Emergency Medicine, University of Cincinnati.

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Funded by a grant from the Emergency Medicine Foundation and by the University of Cincinnati Department of Emergency Medicine. Laerdal Incorporated donated the manikins.

Reprint no. 47/1/87678

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Address for reprints: Michael R Sayre, MD Department of Emergency Medicine University of Cincinnati PO Box 670769 Cincinnati, OH 45267-0769 513-558-4995 Fax 513-558-5791 E-mail [email protected]

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