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Wednesday, November 7, 2018

First Responders Worried about Fentanyl OD? 
Minimize Fear by Quashing that Myth

BY DAN RUNDE, MD

It's not difficult to see how we got here. Every week it seems like there's a terrifying headline about how a drug bust seized enough fentanyl to kill the citizens of a city, state, or even a small country. (The Washington Post May 25, 2018; https://wapo.st/2IZV4rb.) Enough narcotics to kill 26,000,000 people?! That sounds bad.

The article noted that the Drug Enforcement Administration "has even warned law enforcement officers not to touch the white powdery substance or inhale it while on the job." It stands to reason that our colleagues would be worried about the dangers of lapsing into a coma while on the job.

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Fentanyl pills and crystals. (Courtesy of DEA.gov.)

The idea of being forced into an accidental nap might sound lovely if you're a parent of young children, but this is an understandably undesirable outcome to the rest of the working world. The end result: Fentanyl is being banned from courtrooms, officers are wearing hazmat suits during drug busts, police departments are spending hundreds of thousands of dollars on portable fentanyl detection devices (at $46,000 a piece, you could supply every first responder in America with latex gloves), and seemingly endless reports of unwitting professionals nearly overdosing, only to be saved by a timely naloxone administration.

Thankfully, no law enforcement or first responder lives have been lost as a result of this growing crisis, but the fear is real and all too pervasive. The only problem? Accidental fentanyl overdose is not a thing. All those reports you've seen in the news? Not a single one has been verified by an actual toxicologist or physician.

Several cases described toxidromes that more closely resemble panic attacks or, to be more generous, potential methamphetamine exposure. In several others, the accidental overdose victim reported self-administering naloxone. As EPs, we can confidently say that if you can self-administer an opioid overdose reversal agent, then you weren't overdosing on opioids in the first place.

 

Fear of Accidental Harm
I happen to be lucky enough to be friends and colleagues with a brilliant clinical toxicologist, Joshua Radke, MD, whose pharmacokinetic knowledge is rivaled only by his spectacular red beard. I asked him if it was possible to overdose on fentanyl by touching it with intact skin. Dr. Radke said, "Nope, fentanyl isn't absorbed that way. That's why pharmaceutical companies had to spend years and millions of dollars developing a special patch to get fentanyl into the body through skin."


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Joshua Radke, MD


What about these super-fentanyls we keep hearing about like carfentanil? Can that be absorbed through skin? That got another "nope" from Dr. Radke, who added, "It's more potent, but it's not magically more dangerous."

Then what about breathing in fentanyl dust that's kicked up into the air? "Again, very unlikely for two reasons," Dr. Radke said. "First, fentanyl has a low vapor pressure, which means it would be hard to have very much of it floating around in the air. Second, even if it were, you'd have to breathe it in for a really long time, like hours, to get a meaningful amount into your bloodstream."

Last question: Is your amber mane really natural? It's almost impossible to believe it's not chemically enhanced. Said Dr. Radke: "It is 100 percent natural, and 1,000 percent magnificent."

On the off chance that the words of my red-headed colleague don't have you completely convinced, here's a position statement from the American College of Medical Toxicology and the American Academy of Clinical Toxicology echoing exactly what Dr. Radke said but in more highfalutin language: "Fentanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to emergency responders is extremely low. To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids." (Clin Toxicol [Phila] 2018;56[4]:297; http://bit.ly/2J1uSw7.)

          As EPs, we have important partnerships with first responders and law enforcement, and a key part of our interaction should be education, especially when we're talking about a situation that is increasingly common and is subject to so much well-intentioned but incorrect information. Perhaps more importantly, we know the people who use and inject drugs are subject to tremendous stigma, inside and outside the hospital.

If first responders are afraid of touching patients who have actually overdosed and are in need of emergent reversal out of a misplaced fear of overdosing themselves, it puts this vulnerable population at further risk. The same is true for law enforcement—introducing fear of accidental bodily harm into what can already be a potentially fraught interaction is bad for everyone. Our colleagues in these fields have tough and sometimes scary jobs. If we can use our expertise and close ties to help minimize fear and misinformation, we'll be doing a service to our fellow professionals and to our future patients.

Dr. Runde is the assistant residency director and an assistant professor of emergency medicine at the University of Iowa Hospitals and Clinics, where he serves as co-director for the associate fellowship in medical education. He creates content for and is a member of the editorial board for www.TheNNT.com, and is a content contributor for www.MDCalc.com. Follow him on Twitter @Runde_MC, and read his past articles at http://bit.ly/EMN-MythsinEM.

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Wednesday, October 31, 2018

A Career Spent Looking for a Sense of Belonging

BY L.E. GOMEZ, MD, MBA

The analogy of a fish swimming in water with no idea what water is describes an experience I have frequently had with colleagues in emergency medicine. Twenty years ago, I beat my head against a wall sharing with fellow residents and faculty that implicit bias and prejudice were adversely affecting the health outcomes of our patients. In the words of my mostly white male colleagues, they just didn't see it. To them, I simply had a chip on my shoulder.

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  RaStudio & SonofPromise/Thinkstock.com

When it came time for senior grand rounds presentations, I proposed the topic of racial dissonance and miscommunication leading to poor clinical decision-making and health inequity. My program director said no one on the faculty had any expertise in that area, and our department chair said, "I don't think anyone here knows what you're talking about." Several residents shared a conviction that affirmative action was no longer needed because we were serving a largely poor African-American community on the south side of Chicago and "doing these people a favor." One white peer said I should feel fortunate as an African-American to be there. After all, there were now two of us in the program.

My mentors pejoratively suggested I look into a master's in public health, but my black peer and I leaned toward pursuing a master's in business administration, believing we might have more impact as business leaders than as health justice policy advocates.

Twenty years later, the situation in that residency has improved as a result of diversity and inclusion efforts; there is presently a senior black mentor in leadership, and half of the residents in the program are women. Unfortunately, the vast majority of training programs are still swimming in the water of white hegemony; even when managing to achieve diversity, they still struggle with inclusion. Diversity is not inclusion.

My first job as a newly boarded EP was as the associate medical director for a contract management group (CMG) at a Catholic hospital serving a largely Latino community on Chicago's west side. It was gratifying to be the one bilingual physician on staff. The community welcomed me, inviting me to advocate for their interests. The hospital public relations coordinator asked me to record public service announcements on health and safety for our local Telemundo/Univision affiliate.

 

Racist Comments
Meanwhile, I tried to balance meeting benchmarks (already the sole index for increasing revenue) against support for patients struggling against the real determinants of health: social and economic constraints. Cultural competence was not a company priority, even though inclusion was clearly on the hospital's agenda. Any emphasis on community advocacy seemed superfluous to my medical director, who I considered an ally until he made clear he was not interested in how health disparities affected the revenue cycle.

Eventually, the hospital's identity transformed its mission and its market. It became a designated stroke center and tertiary care referral center, shifting its mission to healing ministry rather than serving the local community. The contract group is now long gone, but they still have no blacks or Latinos in senior leadership roles, though they do have an Asian-American vice president. Inclusion seems a threat to some and possibly irrelevant to those not serving minority communities.

With this lesson learned, I moved to a Latino community, in part because I reasoned it would not be made a marginalized market. Here lies one of the greatest hypocrisies and formidable challenges to understanding diversity and inclusion: Latin American society in southern Florida is more vested in white hegemony than Anglo culture is in America. I thought my childhood experience with racist Cuban Americans-in-exile would be different, tempered by my professional credentials, but Cubans on those hospital staffs routinely expressed the racist view that blacks, particularly American ones, are inherently inferior to whites.

I commonly interrupted conversations in the physician lounge peppered with loud references to a black presidential candidate they called "the monkey." This toxic and deplorable behavior is entrenched in the culture. (Recently, a black student movement at the University of Miami was set off by the increased frequency of white students using the n-word and monkey emojis and calling for the enslavement of blacks, all despite the university establishing a diversity task force the year before to combat bigotry.)

Connecting
It was around this time that I moved to a North Miami Beach hospital serving a black community. There I met David Farcy, MD, the president of the American Academy of Emergency Medicine and the chairman of emergency medicine at Mount Sinai Medical Center in Miami Beach, and several other forward-thinking physicians who were becoming increasingly active in the Florida Chapter of the American Academy of Emergency Medicine (FLAAEM) and the National Medical Association in part to call attention to health equity, professionalism, and ethics in emergency medicine practice. A culturally diverse group of professional friends and I put together a TV show called Connections to speak about unity in the minority melting pot of our community, but it was nowhere near enough to put a dent in the inertia of divisiveness.

Minority presence does not equal diversity or impede hostility in the workplace. I set out to acquire the language of the C-suite with a health care MBA and a goal to promote a new model prioritizing health creation and curbing wasteful expenditure on catastrophic care. Everyone knew health disparities lead to a lack of care for chronic disease and the unequal allocation of power and resources. A significant part of the $4 trillion misspent in this country every year could be addressed by funding relatively simple preventive measures. My classmates and I came up with proposals for strategic corporate philanthropic efforts for community-based health care academies and clinics, education for local labor pools, and career paths into training. We researched how clinical documentation systems could be used to help patients save money and limit health expenditures. Of course, this doesn't fit current business models or strategies focused on the next quarter.

It ultimately dawned on us that we could not reinvent the wheel if we wanted to be included in the current health care business structure. Even in meetings set up by a small consulting group I joined later, we never met black people in leadership to champion novel strategies. Being open to diversity does not guarantee it, and health equity requires powerful leaders. I headed north to pursue an interest in policy and advocacy, finally accepting that that might be a better path to health justice. What better area for that than Washington, DC?

I took part in AAEM's Policy and Advocacy Congressional elective while awaiting credentialing at a hospital where I accepted a position as a medical director at a small hospital in a rural farming community. The welcome can best be summed up this way for anyone familiar with the movie Blazing Saddles: I was the new Sheriff Bart. Shortly after I started, two scribes and a unit clerk told me they heard one EP repeatedly make racist remarks about me. I met with him, and he emphatically denied it. I notified our regional director about the issue, and the response was that nothing could be done.

I decided this company was not worth any more of my time and energy. I was active in the National Medical Association, and a colleague suggested I consider the Howard University College of Medicine. I have been practicing there as an associate professor for emergency medicine ever since. There was initially enthusiasm for collaborative work on social justice at Howard, but then the contract was taken over by a CMG.

Diversity and inclusion require integrity and commitment. Last summer while attending emergency medicine lectures at the National Medical Association Scientific Assembly, I ran into the AAEM's president-elect, Lisa Moreno-Walton, MD, who invited me to join the AAEM's Diversity and Inclusion Committee and to speak at the Scientific Assembly. The enthusiasm around diversity and inclusion in most organizations is fueled by avoiding lawsuits and meeting compliance and workplace safety measures. Many diversity and inclusion initiatives and officers are not taken as seriously as other leaders, but I can tell you that even my limited involvement has already been immensely rewarding.

At my first AAEM Scientific Assembly about 20 years ago, I felt isolated and alone as one of a handful of black EPs wandering aimlessly from one lecture to the next. Last year I wandered about expecting that same experience, but the response was more often a positive greeting or suggestion to connect and collaborate. I even came across a young black physician who said he had been wandering around the conference not knowing where to go. "You just made my week," he said. "Thank you for helping me feel part of this."

Dr. Gomez is a clinical instructor in emergency medicine at Howard University College of Medicine and a health care consultant focusing on the economic advantage of diversity and inclusion. He is the chair of AAEM's Diversity & Inclusion Committee. This articles previously appeared in the July/August issue of Common Sense, AAEM's magazine, where his articles frequently appear. (http://bit.ly/2xoLEQH.) Visit his blog at https://liberalartsmd.com, and follow him on Twitter @LiberalArtsMD.

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Wednesday, October 24, 2018

​No Reason Not to Use TXA for Critical GI Bleeds

 BY RICHARD PESCATORE, DO

The application of evidence-based medicine is at its easiest after large trials and rigorous analyses have been popularized and widely disseminated. The evidence-based clinician must juggle online resources, academic manuscripts, and trade journals, but ultimately can remain current through the cornucopia of open-access educational resources available to the modern emergency medicine physician.

A true test of bedside Bayesianism, however, comes when we are presented with clinical conundrums not yet thoroughly vetted and extensively analyzed by contemporary emergency medicine educators. It is when no clear answer exists that we are forced to faithfully apply the best available knowledge to answer critical questions in real time. As methodical skepticism in emergency medicine continues to permeate and propel our evidence-based culture, it is crucial that we not abdicate our underlying responsibility to do what we think is best for the patient in front of us.

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Often, it seems, we treat the absence of compelling evidence as an indication of an intervention's futility or ineffectiveness, which may be a disservice to the patient in need. In reality, a synthesis of the available literature with our clinical experience, individual patient factors, and the medical degrees and extensive body of knowledge we all have fought so hard to obtain is more than sufficient where top-level evidence may be lacking.

Consider the patient dying of a gastrointestinal bleed. It's no rarity—tens of thousands of these patients pass through our doors annually. Emergency medicine residents cut their procedural teeth in resuscitation bays full of GI bleeders and almost every EP has a story about that time he put a Blakemore in. We often lament how little we have to offer these patients while awaiting reticent gastroenterologists.

Octreotide and ceftriaxone are quickly delivered. Proton pump inhibitors are lambasted for their lack of efficacy yet dutifully ordered despite compelling evidence of no benefit and even a signal of harm. We evidence-based clinicians know the literature, and we cling to transfusion trial talismans as we seek to stem the tide of dark blood that seems to flow as quickly as we can replace it. (N Engl J Med 2013;368[14]:1362; http://bit.ly/2NaBTA8; JAMA 2015;313[5]:471; http://bit.ly/2CRG535.)

Curiously, one medication has remained inexplicably absent from our routine resuscitation of the critically ill GI bleeder. Tranexamic acid, or TXA, recently championed in trauma and publicized for every bleeding source from epistaxis (EMN 2018;40[4]:1; http://bit.ly/2Qq5Iux) to abnormal uterine bleeding (EMN 2018;40[3]:5; http://bit.ly/2N7MAmW), often sits unused in the pharmacy as the blood bank is emptied and our patients deteriorate. Despite strong physiologic justification for its use and a level of clinical evidence that should sate even the strictest of EBM evangelists, TXA has yet to find permanent purchase in the GI bleed armamentarium.

We have suspected since 1979 that TXA might benefit critically ill patients with GI bleeds when a small trial of 149 patients demonstrated decreased transfusion requirements and hinted at a mortality benefit. (Scand J Gastroenterol 1979;14[7]:839.) Since then, multiple randomized controlled trials have consistently demonstrated not only improvement in hemodynamic markers and transfusion requirements but also sustained evidence of mortality benefit.

Clot Breakdown
A meta-analysis of seven randomized controlled trials of 1,385 patients in 2008 showed a relative mortality improvement of 39 percent. (Aliment Pharmacol Ther 2008;27[9]:752; http://bit.ly/2xgvIAL.) This was confirmed with a 2014 Cochrane Review, where eight RCTs and more than 1,700 patients found a relative risk for mortality of 0.60, with no difference in venous thromboembolic events. (Cochrane Database Syst Rev 2014 Nov 21[11]; http://bit.ly/2NbRxvc.)

Tranexamic acid reduces clot breakdown by inhibiting the action of plasmin, an active agent in fibrinolysis. The CRASH-2 and MATTERS trials convinced the trauma and emergency medicine communities of TXA's value in reducing death due to bleeding and all-cause mortality in major trauma, and multiple systematic reviews and meta-analyses since then have consistently demonstrated statistically significant reductions in death when TXA is applied in patients with GI bleeds. As is the case in modern evidentiary science, though, medical societies and guideline organizations have (appropriately) called for additional data before making a recommendation to routinely include TXA in the resuscitation of the GI bleeder.

A 2014 trial sequential analysis—a statistical technique that combines information already available from meta-analyses with weighted interim analyses and helps to quantify how much more information is needed before a treatment effect can be confidently confirmed—indicated that 5,500 more patients would need to be included in clinical trials (more than double the number already analyzed) before the mortality benefit of TXA in GI bleed could be confirmed. (BMJ 2014;348:g1421.)

Fortunately, an ongoing RCT, the HALT-IT trial, has recruited nearly 10,000 patients on the way to their goal of 12,000, and should provide definitive confirmation of the benefit of TXA as a life-saving medication. The frustrating part, however, is that the trial isn't set to conclude until next year, and the timeline of publication and knowledge dissemination likely stretches far beyond that.

The question, then, is what we should do in the interim.

Tranexamic acid has shown itself to be safe and effective in a constellation of emergency conditions, and not one but eight randomized trials have reliably established that it saves lives in patients with gastrointestinal bleeding. Overblown fears of precipitating increased rates of venous thromboembolic events have not panned out in large studies across a variety of applications, and the biochemical basis of the drug and its expected action correspond with demonstrated success in clinical trials.

The much-anticipated HALT-IT trial will settle the debate, but in the meantime we are left with consistent and compelling evidence that tranexamic acid should be routinely incorporated into the resuscitation of the critically ill GI bleeder. Our patients deserve nuance and rational integration of the literature where definitive studies are lacking. Our patients deserve TXA.

 Dr. Pescatore is the director of emergency medicine research for the Crozer-Keystone Health System in Chester, PA. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine: http://bit.ly/EMNLive. Follow him on Twitter @Rick_Pescatore, and read his past columns at http://bit.ly/EMN-Pescatore.

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Wednesday, October 17, 2018

'Pull Till Full' Pits Nurses against Physicians

BY EDWIN LEAP, MD

I bring you grave tidings from the land of Emergistan. As the self-appointed and lifelong prime minister of our little country, I feel compelled to share the news that we are all being threatened. By what, you ask? What dark force gathers at the border of our hallowed homeland and threatens the stability and sanity of us all?

Well, lots of things, but I have only this space with which to describe the existential threats to our well-being. The dark force I'm describing goes by the name "pultilfull." An evil ogre if there ever was one.

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                                                                                                                  Eoneren/iStockphoto.com

Of course, its real name is "pull till full." It goes like this: No matter how busy the doctor is, every room in the ED needs to be full if there's a patient waiting. This ideology is in place across the land in departments large and small.

The theory is, of course, that patients are all in imminent peril and only when they are in the ED proper, across from our food- and water-free work stations, are they truly safe. The waiting room, so we are told, is nothing short of a death trap, and the faster we move our charges to the actual ED, the less likely we'll have to carry their stiff corpses directly from the waiting area to the morgue.

When the physician (possibly on single coverage) has eight patients in a small ED, four of whom have chest pain, one who is septic, one sick infant, one with stroke symptoms, and one suicidal—the other beds simply have to be filled and not necessarily with more chest pain, mind you.

Whatever comes in—ankle sprain, asymptomatic hypertension, pediatric chest pain after being hit in the chest—it has to have a room. I don't mean those with abnormal vital signs or risk factors but the patients with a UTI or cough. They just need to have a room to be safe.

Generating Distraction
I've tried to explain my position to nursing administration, and the answer is, "Dr. Leap, they're safer here than they are in the waiting room." To which I asked, "Then why do we have a waiting room? Let's just expand the ED or line the halls with chairs."

"Well, we can't do that; you know that."

So we continue to "pull till full." What happens is that the liability then somehow shifts. I, or another physician, PA, or NP has to be constantly aware of what's going on. It also means we feel a greater sense of urgency to see the next patient, to keep things moving, to massage our numbers.

When every room is full, however, it's a distraction from providing good care to the ones who are here. It also means more people standing in doorways, tapping their feet, asking, "How much longer?" or saying, "Can I have a blanket or a cup of ice?" It means more people wondering why the doctor is just "goofing off on his computer." Distractions are dangerous, and I think "pull till full" creates unneeded distractions.

But whether you think this is a good idea (and I respect you if you do), here's where the whole theory breaks down, fellow Emergistanis. If I'm the only doc with three nurses, we pull till full. "You'll be fine," they tell me.

If the nursing staff feels stretched or if they're a nurse or tech short, however, then patients wait. In the perilous, gator-filled swamp of a waiting room. "They're fine."  If the night physician only has a PA for another hour and wants to knock the numbers down, but the nurses feel overwhelmed, then nobody is coming back, even if there are rooms, even if the chart says, "chest pain."

To review, one overwhelmed doctor, four nurses who are not: Get over it.

Two doctors, three overwhelmed nurses: ED comes to a standstill.

Doctors Against Nurses
Look, I get it. Nurses follow orders from up on high. This is really a national issue of administration and ridiculous customer satisfaction standards mixed with genuine concerns for patient safety. But it's a rule applied unfairly. It puts nurses in the driver's seat of the ED tempo, with physicians having next to no input.

It makes nurses do anything to avoid being yelled at by the people with clipboards running the numbers. If that means every room is full all the time, then that's the way it goes. Unless, of course, that doesn't work for the nursing staff.

I miss the days when we weren't played against each other. When we were all really a team. Those were the days when the physician could say (of a patient he knew well), "That patient doesn't come back until everyone else is cleared out." And it was OK. I miss being in charge. I was responsible for their safety then as I am now. But judgment wasn't a four-letter-word.

I understand that the waiting room can be dangerous. Bring the chest pains back! Bring back the old abdominal pains and dehydrated children and those who are at risk! Sometimes triage actually works, and the waiting room is for waiting. And the waiting room allows us to work more effectively in a way that is safe and sane for everyone involved.

Long live Emergistan! Semper a decem.

Dr. Leap practices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at www.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available at www.booklocker.com, and of a blog, http://edwinleap.com/. Follow him on Twitter @edwinleap, and read his past columns at http://bit.ly/EMN-Emergistan.

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Wednesday, October 10, 2018

​Outcomes Worse for Intubated OHCA Patients

BY RORY SPIEGEL, MD

Airway has been paramount to managing cardiac arrest since the earliest endeavors in resuscitation—the use of tobacco smoke enemas to resuscitate drowning victims on the banks of the Thames was documented as far back as 1746. (Lancet 2002;359[9315]:1442.) Such efforts, while anatomically misplaced, were well intended in principle. We have since discovered alternative preferred orifices through which to ventilate our patients with cardiac arrest, but the exact conduit to deliver these artificial breaths is still unclear.

A growing body of evidence suggests that deemphasizing early definitive airway management may lead to improved outcomes. The majority of these data was observational and prone to the biases associated with such analyses. (Resuscitation 2015;93:20.) Two recently published major trials now give us high-quality data on the role of a definitive airway in managing patients with out-of-hospital cardiac arrest (OHCA).


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Credit: Lippincott, 2012.


The first of these studies, the Pragmatic Airway Resuscitation Trial (PART), was a multicenter cluster-crossover randomized trial in which 27 EMS agencies across the United States were randomized to one of two initial advanced airway strategies, laryngeal tube (LT) or endotracheal tube (ETI) insertion. (JAMA 2018;320[8]:769.) The trial protocol did not limit the number of attempts permitted by paramedics, nor did they dictate the rescue strategies used for a failed airway. The participating EMS personnel followed local protocol to confirm airway placement and OHCA management, including terminating resuscitation efforts in the field.

A total of 3,004 patients were enrolled over a two-year period, 1,505 to the LT group and 1,499 to the ETI group. Compliance with the treatment strategy (defined as the initial attempt with assigned airway or use of BVM only) was high in both groups, 95.5 percent and 90.7 percent, respectively. Success of the initial strategy utilized was significantly higher in the LT group at 90.3 percent compared with only 51.6 percent in the ETI group. The authors reported a statistically significant difference in their primary outcome, survival at 72 hours: 18.3 percent in the LT group v. 15.4 percent in the ETI group.

This survival benefit favoring the LT group remained consistent when the authors examined survival to hospital discharge (10.8% v. 8.1%) and survival with a good neurological outcome, defined as an mRS of 0-3, (7.1% v. 5.0%). The authors also reported higher rates of airway insertion attempts (18.9% v. 4.5%), unsuccessful initial airway insertions (44.1% v. 11.8%), unrecognized airway misplacement or dislodgement (1.8% v. 0.7%), pneumothoraces (7.0% v. 3.5%), and rib fractures (7.0% v. 3.3%) in the ETI group compared with the LT group. These outcomes remained consistent when the authors examined subgroups based on initial rhythm and whether the event was witnessed.

Statistical Noise?
these results seem to vindicate those of us who advocate for a supraglottic approach to airway management in cardiac arrest. The lower rates of neurologically intact survival may well represent the logistical burdens associated with definitive airway management in patients in cardiac arrest. But, as with any study, these small differences are also likely to represent statistical noise, and a larger sample size may demonstrate a regression to the true mean. It seems that the PART results represent the latter, as demonstrated by the AIRWAYS-2 trial published alongside it. (JAMA 2018;320[8]:779.) The authors conducted a multicenter, cluster controlled trial that randomized prehospital providers at four large EMS agencies to a second-generation supraglottic airway device or endotracheal intubation using direct laryngoscopy.

A much larger cohort—9,296 patients—experiencing OHCA was enrolled over a two-year period in AIRWAYS-2. The authors found no difference in their primary outcome, survival with a good neurological outcome (mRS 0-3), 6.4 percent in the supraglottic group v. 6.8 percent in the tracheal intubation group.

In the subset of patients who received advanced airway management (80% of the entire cohort), more patients in the supraglottic airway device group had a favorable outcome, 3.9 percent, compared with only 2.6 percent in the endotracheal group. They also noted that a supraglottic airway device treatment strategy was significantly more successful in achieving ventilation after up to two attempts (87.4% vs 79.0%), without noting any difference in regurgitation or aspiration.

Some would argue that the results of these trials compare a strategy that utilizes a supraglottic device with one that employs subpar use of an endotracheal tube. After all, the first-pass success rate reported by the authors in the PART trial was only 51.6 percent. This imperfection itself may be responsible for the inferior outcomes observed in this cohort. This is a valid criticism, but it is unjust to assume that this failure in airway management was due to a poorly trained group of prehospital providers. The results may simply be due to the acuity of the patients and environment in which these providers find themselves operating.

But let's say for argument's sake that it was due to a lack of training and could be solved by intense remediation. To what end? The AIRWAYS-2 trial reported a higher rate of initial ventilation success, demonstrating at best that ETT was no better than a supraglottic approach. It is a zero-sum game. One could invest in intensive mandatory airway training and video laryngoscopy devices on every ambulance throughout a system to drive up the first-pass success rate, but survival would remain unchanged, diverting logistical and financial resources away from the things that actually matter.

These are two well done large cluster-randomized trials examining broad swaths of the population. A substantial portion of the population did not ultimately receive the intended management strategy, but the pragmatic design of these trials represent the realities of the prehospital environment. These trials examine the logistical complexities and subsequent consequences of an intended airway strategy. They are statistically incongruent, but they likely represent the same underlying truth. Managing the airway is of minimal clinical consequence for a large portion of patients experiencing OHCA. It is an unnecessary distraction for the most part, and the most logistically simple management strategy should be undertaken, which is a supraglottic airway in most cases. The question these data left unanswered is how a supraglottic strategy compares with more minimalistic approaches such as a simple nasal cannula and a jaw thrust. Or even the insufflation of more noxious fumes, like tobacco smoke perchance.

Dr. Spiegel is a clinical instructor in emergency medicine and a critical care fellow in the division of pulmonary and critical care medicine at the University of Maryland Medical Center. Visit his blog at http://emnerd.com, follow him on Twitter @emnerd_, and read his past articles at http://bit.ly/EMN-MythsinEM

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