Out-of-Hospital Endotracheal Intubation: Half Empty or Half Full?

Abstract

Many researchers, emergency medical service (EMS) providers, and emergency physicians are increasingly viewing ground transport, out-of-hospital endotracheal intubation with skepticism. On one side of the debate are those who continue their support of this practice and read the medical literature with concern that the data are incomplete and not exhaustively studied—the glass is half full. This side of the table expresses confidence in the “A-B-C” mantra, cites the progress in out-of-hospital airway management practice, and advises no change until more conclusive data are brought to the subject. On the other side of the debate are those who see the glass as half empty, with no credible evidence that out-of-hospital endotracheal intubation contributes meaningfully toward the reduction of morbidity or mortality in ground transport EMS patients. The discourse from this side has a certain crescendo momentum of late because the evidence has increasingly indicated that out-of-hospital endotracheal intubation may cause more harm than benefit. In this issue of Annals of Emergency Medicine, 2 important contributions appear that add to the discourse: Jacoby et al 1 and Wang and Yealy. Jacoby et al 1 describe a clinical trial evaluating midazolam and etomidate for induction agent–facilitated intubation of adult EMS patients. The stance communicated by the investigators in this trial would suggest that they reside on the half-full side of the out-of-hospital endotracheal intubation debate. Wang and Yealy, in contrast, weigh in with the half-empty view of the debate as they exhaustively review the medical literature that has attempted to assess the outcomes associated with out-of-hospital endotracheal intubation. To place the debate about out-of-hospital intubation practice into the proper context, we must first accept the reality of emergency department (ED) endotracheal intubation. Many patients will require a period of mechanically assisted ventilation during hospitalization. The ED is often the point of initial contact, evaluation, or diagnosis for these patients, necessitating the importance of endotracheal intubation skills for the emergency physician. Modern emergency medicine practice