Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation

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Objective. Paramedics often perform endotracheal intubation (ETI), insertion of a breathing tube, on critically ill out-of-hospital patients. Recent studies highlight important paramedic ETI shortcomings including adverse events, errors, andpoor outcomes resulting from this procedure. Little is known about workforce perceptions of these events. We sought to identify paramedic andphysician perceptions regarding the challenges andpitfalls of out-of-hospital ETI. Methods. We conducted a qualitative study involving paramedic focus groups sessions andindividual interviews with Emergency Medical Services (EMS) physician medical directors. We recorded andtranscribed all sessions. We used inductive theory construction to examine, organize, andclassify thematic patterns. Results. Fourteen paramedics and6 physicians participated. Although paramedics andphysicians recognized problems with paramedic ETI, all participants strongly felt that paramedics should continue to perform the procedure. Physicians andparamedics disagreed about the ability of paramedics to perform neuromuscular blockade-assisted intubation. Both groups identified aspects of paramedic education, skills acquisition, andmaintenance as core issues. Participants also identified broader factors about the structure of emergency services, the role of the medical director, andworkforce culture andprofessionalism. Conclusion. Paramedics andEMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organization, oversight, retention, andprofessionalism. Efforts to improve ETI must include strategies to address multiple aspects of EMS operations andculture.