THE RESEARCH

Jarvis JL, McClure SF, Johns D. EMS intubation improves with King Vision video laryngoscopy. Prehosp Emerg Care. 2015;19(4):482–489.

THE SCIENCE

This study represents an EMS system’s intubation experience before and after implementing a video laryngoscope. Prior to the implementation, while using only direct laryngoscopy (DL), their first pass success (FPS) rate was 44% and their overall intubation success rate was 64%.

The service recognized their performance was below their goal, and with close medical director oversight, attempted to improve by switching from DL to video laryngoscopy (VL).

They chose King Vision because of the quality of view it provided of the cords and usability as measured by paramedic preference during a cadaver lab.

VL proficiency was accomplished with mandatory training that included hands-on practice, lecture and online videos. Medics were required to show competency in VL monthly.

After a phase-in of several months, direct laryngoscopes were removed from the ambulances and all intubations were required to be performed using a video laryngoscope.

Over the course of the study, 514 patients were intubated. There was no difference between the general patient population before and after implementation of VL. Results included the following:

Increase in FPS rate from 43.8% to 74.2%;

Increase in success per attempt (successful attempts/total number of attempts) from 44.4% to 71.2%; and

Increase in overall success rate (successful intubations/number of patient for whom intubation was attempted) from 64.9% to 91.5%.

DOC WESLEY COMMENTS

Endotracheal intubation remains one of the most controversial topics in EMS. One of my primary concerns in its use is competency. Jeffrey L. Jarvis, MD, should be commended for recognizing that his service’s performance was less than optimal. Some have proposed that FPS rate should be close to 80%, second pass at 85% and third pass at 90%.

The challenge is how to improve our medics’ performance. After initial paramedic training, the opportunity to use the operating room for continuing intubation education is rare. It’s even less common with decreasing opportunity to intubate patients due to the increasing use of supraglottic airways as the primary airway device and the emphasis on uninterrupted chest compressions during cardiac arrest. For the EMS system in the study, the average number of intubations per medic was 2.9 per year. Of its 131 paramedics, 12 (9%) had no intubations and 30 (23%) only had one.

Besides improved success rate, these devices often include the ability to record the intubation for both quality improvement and educational purposes. Jarvis initially saw a rapid rise in success rate that declined over a matter of months, and correcting that required monthly testing of competency.

Should your service invest in VL? That depends. How is your success rate? If it’s similar to the service in this study, I strongly encourage you to explore the idea.

Otherwise, perhaps you should consider removing intubation from your service’s scope of practice all together.

MEDIC WESLEY COMMENTS

I love the new science and devices that have been developed to improve airway management. VL has given EMS a new opportunity to change a less-than-optimal success rate.

With any new manual skill that requires the use of a different piece of equipment, training, retraining and practice is imperative to achieving success. This study shows that practice was a large part of the improvement to successful intubations.

It’s the responsibility of educators to require frequent practice and skill verification. But what about those services that have education directors who don’t recognize the significance of repetition and competency evaluation? These are the services that will ultimately fail, even with quality equipment.

Not every service can be as lucky as the one in this study—with strong medical director involvement and a staff of highly dedicated educators.

The cost of this product is very reasonable. It’s money well spent if continued education, training and educational oversight support it, and if the providers are tasked to use it.