Paramedic intubation: patient position might matter.

Objective: Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model.
Methods: The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies. To assess past experience, participants self-reported the number of patients they attempted to intubate in the previous 12 months and the patient positions in which they attempted those intubations. Participants attempted to intubate nonembalmed cadavers in a controlled environment in three positions: on the floor, on a low stretcher to simulate the patient care compartment of an ambulance, and on an elevated stretcher. Paramedics were allowed a maximum of three intubation attempts of one minute each per cadaver. Endotracheal tube placement was verified by a single attending emergency physician using direct visualization.
Results: Self-reports of intubation attempts in the previous 12 months indicated that participants had attempted to intubate a mean of 6.4 patients per paramedic. Self-reported positions of patient intubations were 57% on the floor, 33% in the ambulance, 7% on a stretcher of unspecified height, and 3% in some other position. During the study, 84 paramedics performed 251 intubations on 42 cadavers. First-attempt and cumulative first- and second-attempt success rates were 77.4 and 89.3% for the floor position, 74.7 and 94.0% for the low stretcher (ambulance) position, and 86.9 and 96.4% for the elevated stretcher position, respectively. First attempt success was higher in the elevated stretcher position compared to the low stretcher position (OR = 2.25, 95% CI 1.01-5.00). No other position contributed to greater odds of ETI success either on the first or second attempt.
Conclusions: Endotracheal intubation success was higher with the cadaver positioned on an elevated stretcher compared to a low stretcher. Paramedics must be aware of patient position when performing prehospital intubation.