Saying that EMTs are no strangers to stressful situations would be the understatement of a lifetime.

Our jobs wouldn’t exist were it not for human beings finding themselves in perilous, often life-threatening circumstances. And arguably one of the most stressful scenarios for EMTs is a patient experiencing respiratory distress. In that moment, saving their life becomes the sole mission.

Let’s explore some advanced airway procedures to help when you find yourself trying to help a patient going into respiratory distress.

Importance of Airway Management Training

Treatments and procedures that allow EMTs to save lives largely depend on expertise, training, and credentials like advanced cardiac life support (ACLS).

Intubation secures the airway, but not all EMTs have the training to intubate patients. So then what?

“If you arrive on scene for a cardiac arrest and cannot establish an endotracheal intubation, our second airway of choice is the king LT airway,” said Shawn Nicholson, EMT-P of Medstar Mobile Health Care in Fort Worth, Texas. “EMTs can do King LT airway, which is not a full intubation.”

As a preceptor for college students with 31 years of experience in 911 systems and 20 years as a paramedic, Nicholson shares some tips to help EMTs master advanced airway procedures.

He said using the King LT, a supraglottic airway device, is considered an effective took for basic airway procedures. It is nearly as good as an endotracheal intubation, especially for EMTs who lack intubation training and experience.

“The King goes into the esophagus, right below the trachea,” Nicholson said. “When you blow air in, the air automatically goes into the lungs, you’re blocking everything off except the trachea. For some patients, if the King airway is in place, some hospitals leave the airway in place because you can oxygenate the patient and are still protecting the patient’s airway.”

Difficult Advanced Airway Intubations

A difficult airway is defined with several criteria, according to a 2018 chapter in the book “Intubation: Difficult Airway”:

  • Having difficulty with intubation
  • Problematic ventilation with a facemask
  • Issues with laryngoscope visualization

Depending on whether a patient is considered high risk based on Cormack-Lehan grading system, intubation failure can occur with some patients.

As a preceptor and employee at Boston Med Flight, Mark Saia, RRT, NRP, FP-C, treats some of the most critical patients from the back of a helicopter. He attributes successful airway outcomes to his extensive training and the colleagues by his side.

Training is one of your best assets when it’s time to intubate a patient with a difficult airway.

Difficult airway intubations fall under high acuity low incidence (HALO), he said. Since you won’t be perfecting difficult airway intubation skills in the field every day, the next best thing is ongoing training, he said.

Airway Protocol Training

At Boston Med Flight, staff go through “aggressive difficult airway protocol training” on a regular basis, he said.

“We all have to do simulation time every year with several scenarios and sessions in our simulation center geared toward difficult airway,” Saia said. “The simulation mannequin can be adjusted so we can go through our difficult airway algorithm … and we have to do airway intubations in front of different medical staff on a quarterly basis and live intubations in the operating room.”

His team also has extensive tools and medications used for airway procedures, he said. And the protocols are just as extensive, he added. Prior to intubations, they run through an airway checklist to prepare for the procedure.

“We have an airway checklist and when we approach an airway during an intubation, we read it out loud,” he said.

Saia attributes their endless training, continued pre-planning, and having the right tools and medications for their overall success. But he doesn’t take it lightly and expressed a certain reverence about his work.

“With these tools comes a tremendous amount of responsibility because with some of the medications, every time you do a procedure there are risks with medications,” Saia said.

Saia was referring to medications like Ketamine and Etomidate, administered intravenously with an anesthetic agent, and neuromuscular blocking drugs.

“Continue practicing anything that would require retention of skills,” Saia said. “And that goes for practicing on all age groups, including infants, kids, and adults.”

Smooth Intubations Require a Calm Mind

In those chaotic moments where the patient’s life is in your hands, the adrenaline can easily take over. But don’t let it.

Nicholson said one of the most common mistakes EMTs make during high-risk procedures, like intubations, is a lack of focus. And understandably so.

He suggests finding a way to “blur out” the background noise as much as possible.

“You have to stop, take a breath, and focus on your skills,” Nicholson said. “There are tons of things going on when it comes to the airway. Focus on your airway because that is the most important thing. When you’re about to go in with a laryngoscope, take a deep breath, and hit all your marks.”

During intubation, everyone has their role. One person handles CPR while another checks medications making team communication critical, Nicholson said.

Just prior to intubation, let your team know you are about to intubate the patient to allow you to focus on the airway, Nicholson said.

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