The Real Gold Standard Of Airway Management

Posted by Patrick Lickiss on Sep 23, 2010 in EMS 2.0, General, Treatment | 1 comment

Okay, I’ll admit it, the title of this post was intentionally provocative.  I’m assuming some of the readers came in ready to fight, but hear me out.  Of the discussion among the EMS community through blogs, podcasts and Twitter, a huge majority center around a few topics:  intubation, pain management and helicopter usage.  Since I’ve entered the fray of the helicopter discussion, I thought it might be time to take on airway management.

GOLD STANDARD
The term “gold standard” gets thrown around pretty frequently during these types of discussions.  The term usually comes up in a sentence like:  “The gold standard for airway management is endotracheal intubation.”  Now I have an issue with several parts of that sentence, but let’s take them one at a time, starting with the term “gold standard” itself.

The handy Dictionary.com app on my phone provides the following definition:

gold standard
- noun
monetary system with gold of specified weight and fineness as the unit of value

Well that certainly doesn’t seem like the definition people have in mind.  How about this entry from a slang dictionary:

gold standard
- noun
2.  a paragon of excellence

Well that’s definitely closer.  So there you have it, intubation is the paragon of excellence against which other airway management procedures should be judged.  But is it really?

WHY A GOLD STANDARD?
So what is excellence in airway management?  Or, put another way, why manage an airway? Sure we work to ensure that a patient is able to maintain oxygenation.  And we want to protect from aspiration, but to what end?  Ultimately, we want our patients to exchange gasses.  In with the good, out with the bad.  Oxygen in, carbon dioxide out.  Now if only we had a way to measure the quality of gas exchange in our patients.  Enter capnography.  Since the only way a patient is able to take in oxygen and exhale carbon dioxide is through a patent airway, capnography presents us with a way to not only ensure that the airway is clear, but that circulation is adequate.  Seems pretty good to me!

A NEW GOLD STANDARD
So if the gold standard for airway management is something concrete, like adequate gas exchange, then the achievement of that standard is left up to the practitioner.  Systems with fewer paramedics who have high intubation success rates (or use devices like the Glide Scope) can opt to use intubation to achieve that standard.  Systems with more paramedics than they know what to do with can stick with alternative devices that ensure adequate gas exchange.  Heck, crews can use an OPA and BVM (with in-line capnography; it works, try it!) for certain full arrest patients because they can show both quantitatively and qualitatively that gas exchange is being accomplished.

RETHINKING THE STANDARD
Ultimately, we should begin considering outcome-based standards.  Rather than dictating a certain procedure as the “gold standard”, pick an outcome or a goal and let each system design a method for achieving it.  Part of the EMS 2.0 movement is the realization that EMS will look different to different people in different systems.  Rather than putting all our weight behind procedures and drugs with little if any evidence to support their use, we should focus on outcomes and empower our practitioners to accomplish those outcomes.