Man...lots of people with panties in a wad. Keep in mind that emergency medicine is a specialty of breadth, we know a little about a lot rather than a lot about a little. We don't claim to be the experts in intubating, in delivering babies, in running traumas, or even managing critical patients. What we do claim to be is available. In the ivory towers it is easy to get a trauma surgeon, an anesthesiologist or an OB in the ED in a matter of minutes. However, where MOST physicians practice, this simply isn't practical. So the EPs gotta do it. We do the best we can, and for the most part, take excellent care of our patients, and know when we're getting into a situation beyond our abilities. At that point, yes we consult. We don't do 500 airways as a first year resident. In fact, many EM residents graduate with only 100-150 intubations. A high percentage of those are "trauma airways" and most programs give excellent training with alternative airway management techniques. I've used a light wand, intubating LMA, fiberoptic, Glidescope, mac blade, miller blade, bougie, crich, needle crich (cadaver) etc. Are we better at managing "crash airways?" Don't know. The only data I've seen seems to indicate that senior anesthesia residents and senior EM residents are equivalent at securing the airway of trauma patients and that both get nearly all of the intubations presented to them. I've had anesthesia called to the ED for exactly 1 intubation during my residency. It was a pediatric multiple trauma where the trauma surgeons had some concern the tube wasn't in due to the patient's sats not improving despite bilateral chest tubes, ETCO2 confirmation, and direct visualization of the tube passing the cords. Turned out the trachea had a large laceration in it and one of the bronchi was detached from the trachea. The patient certainly didn't improve after the anesthesiologist replaced the tube. (Later declared unsalvageable in the OR)
Like with any procedure, there is a learning curve. It is steep at first, but certainly continues to climb no matter how many one does. I think the only point I'd dispute is that a CA-1 is a better intubater than a residency trained EM attending who has been practicing in a high acuity facility for 10+ years. But who knows, I could be wrong. Someone want to do a study? I suspect it would have to be huge to actually show a difference.
Ann Emerg Med. 2004 Jan;43(1):48-53. Related Articles, Links
Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.
Levitan RM, Rosenblatt B, Meiner EM, Reilly PM, Hollander JE.
Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
[email protected]
STUDY OBJECTIVE: We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis. METHODS: Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days. Emergency medicine residents intubated patients who arrived without notification or who needed immediate intubation before anesthesia arrived. The study was conducted in an inner-city, Level I trauma center with approximately 50,000 ED patients and 1,800 major trauma cases a year. Main outcomes were success or failure at laryngoscopy and the number of laryngoscopy attempts needed for intubation. RESULTS: Six hundred fifty-eight trauma patients were intubated during the study period. Laryngoscopy was successful in 654 of 656 cases. Two (0.3%) patients underwent cricothyrotomy after failed laryngoscopy, and 2 (0.3%) patients had awake nasal intubation without laryngoscopy. The specific number of laryngoscopy attempts was unknown in 6 cases (3 from each service), resulting in 650 cases for laryngoscopy performance analysis. Overall, 87% of patients were intubated on first attempt, and 3 or more attempts occurred in 2.9% of patients. Laryngoscopy performance by service (broken down by 1, 2, and >or=3 attempts) was as follows: emergency medicine 86.4%, 11%, and 2.6% versus anesthesia 89.7%, 6.7%, and 3.6%. Analysis by service was done by using Wilcoxon Mann-Whitney testing (P=.225). CONCLUSION: There were no differences in laryngoscopy performance and intubation success in trauma airways managed on an every-other-day basis by emergency medicine versus anesthesia residents.
J Trauma. 2001 Dec;51(6):1065-8. Related Articles, Links
Role of the emergency medicine physician in airway management of the trauma patient.
Omert L, Yeaney W, Mizikowski S, Protetch J.
Department of Surgery, Allegheny General Hospital, South Tower, Pittsburgh, Pennsylvania 15212, USA.
BACKGROUND: A Level I trauma center recently underwent a policy change wherein airway management of the trauma patient is under the auspices of Emergency Medicine (EM) rather than Anesthesiology. METHODS: We prospectively collected data on 11 months of EM intubations (EMI) since this policy change and compared them to the last year of Anesthesia-managed intubations (ANI) to answer the following questions: (1) Is intubation of trauma patients being accomplished effectively by EM? (2) Has there been a change in complication rates since the policy change? (3) How does the complication rate at our trauma center compare with other institutions? RESULTS: EM residents successfully intubated trauma patients on their first attempt 73.7% of the time compared with 77.2% ANI. The overall success rates, i.e., securing the airway within three attempts, were 97.0% (EMI) and 98.0% (ANI). The airway was successfully secured by EMI 100% of the time while a surgical airway was performed in two ANIs. CONCLUSION: EM residents and staff can safely manage the airway of trauma patients. There is no statistically significant difference in peri-intubation complications. The complication rate for EDI (33%) and ANI (38%) is higher than reported in the literature, although the populations are not entirely comparable.
Acad Emerg Med. 2004 Jan;11(1):66-70. Related Articles, Links
A comparison of trauma intubations managed by anesthesiologists and emergency physicians.
Bushra JS, McNeil B, Wald DA, Schwell A, Karras DJ.
Department of Emergency Medicine, Temple University Hospital and School of Medicine, Philadelphia, PA 19140, USA.
[email protected]
Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. OBJECTIVES: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. METHODS: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46-month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. RESULTS: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). CONCLUSIONS: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists.