Working in Wisconsin, Dr Lenz is Medical Director of Flight for Life, the critical care air medical transport program serving this upper mid-western US state. Typically, the medical crew onboard the organization’s helicopters comprises of one flight nurse and one flight paramedic, but occasionally there are two nurses. And when it comes to the special skills each type of medic possesses, there are key differences in qualifications and practical applications.

Intubating a patient who has been shot or seriously injured in a car accident is going to be difficult and time-sensitive, and Dr Lenz is adamant that everyone has to be able to provide the patients they serve with the care they need. “Intubation is the highest-stake skill we have,” said Dr Lenz, “and we need to make sure the whole crew can do it.”

Crews often overestimate their abilities when performing intubations

Research carried out by Dr Lenz and his team has found that crews as a whole think they are better than they actually are when it comes to intubation. Their first-pass success rate might look good on the surface, but closer examination can reveal where there are gaps in skills when one compares nurses to paramedics.

Dr Lenz points out that his research shows that video tends to be relied upon more by nurses, while paramedics tend to go direct. “They need to be proficient in both,” said Dr Lenz, “and break the mentality that one is better than the other. What I’d like to see,” he continued, “is an increased use of bougies, especially in austere environments like car accidents, as they can make a real difference to the outcome of the intubation.” 

“At first glance,” he observed, “we have noticed what appears to be higher first-pass success when a bougie is used. It is smaller than the endotracheal tube, and when used with video laryngoscopy, appears to be more easily passed into the trachea. This is from a bird’s eye view with no real data, but something I am looking into more.”

Video intubation systems are a useful tool, but can be imperfect

Video laryngoscopy was undoubtedly a step forward in many ways for complex airway management in a prehospital setting, but it can’t always be relied upon 100 per cent. Technology, after all, is an imperfect science a lot of the time. When training, Dr Lenz relies on the C-MAC video intubation system for his students and crews, which allows him to keep the screen to himself so they don’t always get the benefit of the video, but he can use it if it’s of benefit to the student.

“I use the screen so I can see what the student or resident is seeing without looking over their shoulders,” commented Dr Lenz. “It gives them the added experience of direct laryngoscopy, and I can help guide them to a successful intubation from what I see on the screen. If they are having difficulties with direct intubation, I turn the screen so they can visualize it for themselves.” 

Is the tendency towards video or direct laryngoscopies something to do with a generational shift? “Not necessarily,” said Dr Lenz. He pointed out that air medical crews can often stay in the same job for a very long time, and become accustomed to doing things a certain way. There is a new generation of recruits, though, that wants to learn about all the different methods of performing a task, and this is crucial for improving outcomes and ensuring that any member of the team can perform a procedure when called upon. After all, many helicopter emergency medical service (HEMS) operations are run with two flight nurses and no paramedic, and those nurses need to make sure their skills are equal to the task at hand.

Flight for Life runs airway labs for its crews, and runs a difficult airway course using a high-fidelity patient simulator. Not only this, but because of the organization’s partnerships with two nearby hospitals, crewmembers are actually able to go into the operating room and perform intubations on real-life patients. No simulator, though, can ever recreate the reality of a complex airway that has to be managed in a ditch at the side of the road.

Oddly, Dr Lenz found that his intubation success rate was better at the side of the road than it was in the emergency department (ED) – the 'controlled chaos' of the ED, as he called it, was not what he was used to. He elaborated: “I found this at the start of my training, the early part of residency. It was something I was not accustomed to. Now, I am very successful and a go-to colleague in the ED when there are difficult intubations.”

Medical education is critical in a HEMS setting, however not all education is equal

“Education in a HEMS setting,” said Dr Lenz, “differs for nurses and paramedics.” Airway management training, specifically, tends to take a different focus. Flight paramedics tend to do intubations, which can put nurses at a disadvantage as they practice less, which results in an erosion of basic skills in which the crew had previously been proficient. This is particularly true in austere environments such as the typical scene calls to which HEMS units respond.

“We have to lose the mindset that paramedics have to be the ones performing the intubations,” said Dr Lenz. Ways to improve airway management, particularly in complex patients, can be as simple as setting up a dashboard that keeps track of who is doing the intervention, and then making sure that there is a fair and equal rotation among the crew, which allows everyone to keep their skills razor sharp.

“I still do it in the ED now,” he added. “Every so often, I’ll take over an intubation because I need to make sure I am still proficient.”

Although intubations may not always be required, being well practiced is important

Flight for Life’s mission statistics show that around 30 per cent of calls are to scene – mostly car accidents – while the rest are inter-hospital transfers, usually for cardiac patients. So actually, the majority of the time, the crew won’t be intubating a patient as they will already be intubated (if needed) for the transfer.

“We normally do around 60 to 80 intubations a year, but actually in 2021, our crews only performed 30,” said Dr Lenz. “It is unknown as to why there were much fewer than normal, but this could definitely be related to Covid. I do not have evidence of this, but it could be related to patients being intubated prior to our transfer from the receiving facility, or other non-invasive measures being taken, such as OptiFlow, CPAP, or BiPAP.”

But what it has demonstrated without a doubt is that the crews need education and practice on complex airway management. If they aren’t seeing the patients, they need to practice – either on a mannequin or in the OR.

“We have to keep our skills fresh,” Dr Lenz concluded, “and airway management education is key to ensuring good outcomes in prehospital medicine and HEMS settings in particular.”