Paramedic perceptions of challenges in out-of-hospital endotracheal intubation.

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, and poor outcomes resulting from this procedure. Little is known about workforce perceptions of these events. We sought to identify paramedic and physician perceptions regarding the challenges and pitfalls of out-of-hospital ETI. METHODS We conducted a qualitative study involving paramedic focus groups sessions and individual interviews with Emergency Medical Services (EMS) physician medical directors. We recorded and transcribed all sessions. We used inductive theory construction to examine, organize, and classify thematic patterns. RESULTS Fourteen paramedics and 6 physicians participated. Although paramedics and physicians recognized problems with paramedic ETI, all participants strongly felt that paramedics should continue to perform the procedure. Physicians and paramedics disagreed about the ability of paramedics to perform neuromuscular blockade-assisted intubation. Both groups identified aspects of paramedic education, skills acquisition, and maintenance as core issues. Participants also identified broader factors about the structure of emergency services, the role of the medical director, and workforce culture and professionalism. CONCLUSION Paramedics and EMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organization, oversight, retention, and professionalism. Efforts to improve ETI must include strategies to address multiple aspects of EMS operations and culture.