National Scope of EMS Practice


Let me say at the outset, that there should be no such thing. Why you ask? Because there is no one size fits all solution for EMS. There are something like 50 different models of EMS delivery in North America. They include fire service based, volunteer fire service based, volunteer NON fire service based, municipal BLS service private hospital ALS, municipal ALS service with private ambulance service based BLS transport, volunteer BLS with private or hospital based ALS, police based BLS with private ALS, police based ALS, paid fire based BLS with private ambulance ALS, fire based ALS with private ALS transport (?), paid non profit ALS that provides EMS to municipalities, third service (county, city, region) ALS, fire based ALS that provides both emergency and non emergency transfer service. All but one of those models are in use in one state (mine), and there are other models in use in other areas.

Add to that the varied geography and hospital capabilities in the 50 states. Sorta Big City EMS had transport times that were generally under 10 minutes and more than one Level 1 trauma center to pick from. A close friend of mine used to be one of TWO paramedics for her service. The nearest Level 1 trauma center was two hours away by ground transport. That was on a good day, not during the frequent winter storms her region experiences. During those periods medical helicopters are usually not flying, also due to weather. As a result, my friend knew, and still knows, far more about critical care transports in the emergency setting than I ever did.

Where I would have time to do a 12 lead (maybe more than one), start an IV, give medications, and maybe use CPAP, she’d do all of that and have to manage ventilator settings, IV pumps, and and medications I never had to deal with during my career.

On the other hand, I would usually have at least one opportunity to intubate a patient every month. I had a partner who did four intubations in four consecutive shifts. That was pure luck of the draw, he wasn’t a particularly aggressive paramedic. Our system required 12 intubations per year or the paramedic would have to go back to the OR to get experience. I never heard of that actually happening, so intubation opportunities weren’t an issue. Nor were other skills. It was pretty routine for paramedics to do 5 or more IVs during an eight hour shift.

I told you all of that, so that I can tell you this.

Intubation is a dying art in the majority of EMS systems.

Good friend Dave Konig has a post up Is ET Intubation Joining Backboards In Protocol? Dave makes some good points, including the one about the apathy over a petition regarding decent pay for EMS professionals. Don’t start me on that topic, please. However, Dave also misses the point in a way. All EMS systems, like all EMS providers, are not created equal. Nor are all paramedic programs.

Here are some of the factors which are likely to have more impact on the subject of intubation than any studies.

First, it’s getting harder to find hospitals that will allow paramedic students to do rotations in operating rooms. My state used to require paramedic students to perform a minimum of 10 OR intubations during their hospital rotations. When I was affiliated with a paramedic program, it was very hard to find clinical sites, harder to find clinical sites that would give OR access, and when students were there, it was often several weeks before they could meet the requirement.

Add to that the fact the intubations are less common in hospital ORs than they used to be. For short term (less then two hour) procedures, the Laryngeal Mask Airway (LMA) has replaced the Endotracheal Tube (ETT)  in the majority of cases. LMAs are very easy to insert successfully in most patients. Some states even allow them at the BLS level. For elective procedures, where patients vomiting is not a concern, they are ideal for short term use. They are not optimal for pre hospital use, but they are acceptable “rescue airways”.  Teaching hospitals are going to prioritize opportunities for residents and interns over paramedics. Non teaching hospitals are going to just have fewer opportunities overall.

Second, the use of CPAP in the field for CHF and Asthma patients has reduced the need for intubations. There are just fewer patients for whom there is no alternative to intubation.

Third, there are just too many paramedics in the field. All ALS systems in particular suffer from this. If you have 20 ambulances staffed and each one has a paramedic, there are going to be fewer opportunities to intubate just because of numbers. If you have two paramedics per ambulance, it’s even worse. At least anecdotally, systems that have a lower percentage of ALS providers have not only higher numbers of intubation opportunities and a higher success rate.

That, of course goes for every other ALS skill as well. If you only get one IV attempt per week, your skills are going to, not to be too blunt, suck. If you get one ETT attempt PER YEAR, imagine how proficient you’ll be. On the other hand, if you get an ETT attempt once a week, chances are you’ll be more proficient.

Simulation labs can help, but can’t fix the problem entirely. Plus, not everyone has one available and if you have to rent time in one, it gets expensive.

Finally there is oversight. Most EMS systems don’t have full time medical directors and some that do have medical directors that are subordinate to managers be they Executive Directors or Fire Chiefs. It’s not unheard of for a sound clinical decision to be undermined or overruled by administrative concerns. A full time medical director with sufficient resources and the authority to deal with paramedics that do not meet clinical standards seems to be a rarity. Which means that problems are often not detected until something catastrophic happens to a patient. Then the general reaction is to fire the paramedic, strip him or her of their certification, and claim the problem “fixed”.

Remember, it’s not malpractice to incorrectly place an ETT. The malpractice comes when the paramedic fails to recognize or fails to believe that the tube in the wrong pipe and fails to take immediate corrective action. End Tital Carbon Dioxide (ETCO2) monitoring has made confirming correct (or incorrect) tube placement much more certain than it was for most of my active career. ETCO2 takes the guess work out of intubation to a large extent. EVERY paramedic should be using it, understand what the Capnography (waveform) and Capnometry (number value) are telling them. Or in some cases what those values are screaming at them.

Here is how this controversy should play out, but not how it probably WILL play out. There should be a Best Practices document that outlines the criteria that should be met for an ALS system to be able to utilize intubation in the field.

Some of those criteria are,

Every ETT attempt, successful or not, should be reviewed by the medical director or his/her designee.

There should be a minimum number of intubations per medic per year. That’s successful intubations.

Every intubation attempt, successful or not, must be documented completely on the Patient Care Report.

Every intubated patient should have follow up on their hospital course. This can be difficult as hospitals will often hide behind a false interpretation of “HIPAA” to deny information to staff from EMS agencies. There is more than a bit of evidence to suggest that some patients, particularly trauma patients, do worse if they are intubated too early.

Every EMS system that utilizes ETT must track both the agency and individual paramedics success rates, complication rates, and compliance with documentation.

Every EMS system ETT must have access to a Sim Lab or an OR for remediation and skill maintenance as needed.

I’m sure that there are other criteria that I haven’t listed, but that’s the basic outline of how I think it should work.

In the end, I think that the majority of EMS systems will move away from ETT and go to other methods of airway control. Even in systems that still utilize ETT, there will be some paramedics authorized to intubate and some that are not.

Of course we’ll likely need a counseling program for all of the bruised egos this will cause, but that’s just the way it goes.