Limits of replacing prehospital emergency physicians by paramedics: Systematic literature review on success of prehospital endotracheal intubations by paramedics and prehospital emergency physicians

Abstract

Background: In their ninth statement, the government commission on modern and need-based hospital care endorsed extensive replacement of prehospital emergency physician’s attendance in emergency medical services by paramedics. However, in highly invasive and potentially life-saving procedures, it seems questionable to what extent these can be performed satisfactorily by paramedics. We performed a systematic literature review on prehospital endotracheal intubation by paramedics and prehospital emergency physicians and compared the results in order to evaluate this question. Methods: We performed a systematic literature review on pubmed.gov (National Center for Biotechnology Information, U.S. National Library of Medicine, Rockville Pike, Bethesda MD, USA) regarding first pass success, overall success and unrecognized oesophageal intubations by paramedics and prehospital emergency physicians. We used the keywords “prehospital”, “intubation” and “success”. We included prospective and retrospective studies that provided data from the same emergency medical service systems. The results were displayed in a table and a narrative synthesis of the results was used. Results: A total of 523 publications were identified, of which 8 studies were included for further investigation. Even in paramedic-based emergency medical service systems, prehospital emergency physicians are often an integrated part of regular response, as 7 of the 8 enclosed studies demonstrate. Emergency physician-led teams had a higher success rate for intubation, even when intubation was performed by the paramedic. Intubation success rates of non-emergency-physician-led teams was poor. The qualification of the emergency physicians had a high impact on intubation success rates in the investigated studies. Conclusion: Highly invasive procedures, like endotracheal intubation, need sufficient expertise. Performance of these procedures by paramedics is therefore likely problematic. Involvement of ground-based prehospital emergency physicians will therefore still be needed in the future. The qualifications required for prehospital emergency physicians should be raised to meet the demands.