Some may read the title of this article and feel an outcry of injustice as endotracheal intubation (ETI) has progressively been phased out from routine paramedic practice in the UK. This decision is naturally evidence-based with a consensus that a lack of exposure and practice to assure competency increases the risk of a failed intubation attempt (College of Paramedics, 2018).
Research, however, is only one aspect to take into account when considering such recommendations. After all, is it the responsibility of the individual to maintain and practice scope as stipulated by the Health and Care Professions Council (HCPC) (2023), does it fall to systemic governance (the ambulance service), or are both equally responsible?
This fourth and final part in the ethics series focusing on justice will explore scope, using ETI as an example, and consider how ethics can be used to support, or refute, claims of competency on an individual and distributive level.
The individual
Imagine for a moment, that there are three paramedics at different stages in their careers:
Each paramedic is working within their scope and limitations. Therefore, there is no reason for a service to impede ETI provision, other than to provide equipment. The issue is futility and what would be considered a reasonable action to a patient that others could not reject (Scanlon, 1998).
If a patient was in a situation where an SGA is ineffective, but ETI might harbour increased success – defined here as increasing time to definitive care (Iserson, 2006) – it could be argued that Paramedic C is less able to provide care that Paramedics A and B are capable of delivering. This would be irrespective of whether any attempts performed by A and B are successful, since the ETI attempt would only be considered in the event of an SGA failure. The chance of success – no matter how small – remains a positive outcome, where inaction would otherwise result in airway management failure; the evidence suggests a 79% success rate for ETI (Benger et al, 2018). Therefore, ETI in the event of SGA failure is not a futile gesture and is unfair to the patient that ought to be owed every chance to survive.
The importance of such a claim pertains to the individual paramedic's prerogative to enact, to the best of their abilities, optimal management of the patient. If a paramedic were to reject an SGA attempt in favour of an ETI, such an action would be considered inappropriate and subject to a fitness-to-practise concern as a result of incompetently applying an evidence-based process (HCPC, 2023). In addition, if a paramedic were to attempt an ETI when either not competent, or when a more competent resource, such as a critical care paramedic, is available, then for similar reasons, the action is unjustifiable.
Therefore, there are circumstances in which paramedic ETI ought to be enacted:
However, the likelihood of these events ever arising is improbable; there are approximately 30000 out-of-hospital cardiac arrests annually in the UK, 20% of which are non-cardiac related (Perkins et al, 2021). Although an overestimate, within non-cardiac events, it can be supposed that a range of conditions such as occluded airway complications or high pleural inflation pressures (for example, asthma) might be present, where ETI could be considered a benefit compared with an SGA. This represents a cohort of 6000 patients annually, or 16 patients daily. For a greater picture, ambulance services in the UK manage approximately 7.5 million patients face-to-face annually (Association of Ambulance Chief Executives (AACE), 2024). Thus, the potential ETI cohort represents 0.0008% of the workload (1 per 800000 patients). Without adjusting for the availability of a critical care resource, 16 daily patients UK-wide, even as an overestimation, are likely to be covered by an appropriate resource; the incidence of ETI required is negligible. With such a low exposure and demand for ETI, and appropriate critical care resource distribution, as per Rawls (1973), maintaining ETI as a routine scope of paramedic practice is therefore redundant.
System standards
While the previous argument should be sufficient to conclusively refute ETI as routine scope, there needs to be an assurance to patients that there is a minimum expected standard delivered from paramedics. As alluded to earlier, and in the previous article in this series (Robinson, 2023), cost is a factor. It would be costly for a service to provide competency training to ensure that all paramedics retain ETI as a standard scope. Since services do not routinely require ETI, it is justifiable to reduce the minimum standard to SGA in favour of saving cost (and time training).
The same approach can be adopted towards equipment provision: SGAs will cover the larger cardiac patient cohort as effectively as ETI (Benger et al, 2018). Although there is an argument that removal of SGAs would provide a degree of cost saving (ETI equipment is still required for foreign body obstruction and emergency tracheostomy management (AACE, 2022)), the risk of harm and subsequent litigation ought to dissuade any service from making such a decision.
Providing SGA as an assurance standard does not negate the individual paramedic from wanting to maintain ETI competency of their own accord for future practice, so long as they do not apply it against service policy. This is an interesting point since skills are often a desirable quality for any professional or prospective employer. One could argue that an employer who overtly limits scope might result in paramedics – Paramedic A, as an example – seeking working environments that promote greater autonomy and scope, within service or beyond.
There is a diversification of paramedic practice in a variety of settings such as primary, urgent and palliative care. How, for instance, can a prescribing paramedic, or one that can perform ultrasound or operate syringe drivers, be standardised? At present, those who can apply such skills could greatly benefit patients but are restricted by service standardisation and cost limitations. Would it be fair to allow paramedics with such scope to practise these skills in an ambulance within a non-specialist role? Probably not, and this remains a complex distribution issue beyond the purpose of this article.
Likewise, promising interventions such as fascia iliaca compartment block for hip fracture (McRae et al, 2015; Evans et al, 2019; Wennberg et al, 2021) should be on the cusp of paramedic scope standardisation and implemented in service practice owing to a much larger patient cohort (Möckel et al, 2022). Will services be quick to adapt and evolve, and encourage paramedics to upskill as evidence suggests? Would existing paramedics be willing to increase their scope?
Conclusion
This article has touched upon the complex nature of individual scope versus standardisation in relation to contractualism. ETI has been used as an illustrative example, arguing that despite plausible utility in certain circumstances, the incidence remains negligible for standard day-to-day benefit to patients. Further, services can assure standards to service providers by clearly outlining scope. In the context of ETI, this can be perceived as limiting practice if services do not fully clarify why such an intervention has become redundant.
From the lens of contractualism, practice evolves, and in a system where specialist resources are available, it is fair and reasonable to shift the skillset based on demand. Yet, this issue is complex since paramedics are diversifying and capable of learning new skills that are difficult to standardise. Demand for ETI may be low, but other interventions, such as prescribing, effective pain management such as nerve blocks, and wound management, are much higher. They are also suspected to be more cost-effective and provide overall benefit to patients in ambulance service settings.
Ambulance services need to ensure standards that are fair and safe for patient care. However, they may need to develop flexible processes that remain competitive with alternative settings such as primary, urgent, and emergency care. These settings can both broaden scope, yet possibly limit paramedics from returning to the prehospital setting and applying developed skills. After all, paramedics owe it to patients to act within their own scope of practice, and it may not be right, depending on the skill, for services to impede this.