Who manages airways for trauma patients in emergency departments?

As emergency medicine has emerged as a distinct medical discipline, there has been a shift in responsibility for a key task in emergency departments: Managing emergency airways to help patients get enough oxygen. But how widespread is that shift?

That’s the key question that a pair of University of Colorado Department of Emergency Medicine physicians and a medical student set out to answer through a survey of their peers nationwide. They wanted to learn whether it’s anesthesiologists or emergency physicians who oversee airway management for trauma patients in emergency departments across the country.

Joseph Brown, MD, FACEP, an assistant professor of emergency medicine, and Cody McIlvain, MD, an emergency medicine instructor/fellow, led the study. Both Brown and McIlvain practice at UCHealth University of Colorado Hospital (UCH).

They were joined in the research by Ethan Coit, MD, who at the time was a med student and is now in the Denver Health Residency in Emergency Medicine, where Brown is an associate program director.

Brown has trained and worked at four different academic medical centers, “and each one was slightly different in how they managed this. When I was at University of California, San Francisco, for example, anesthesia and emergency medicine would alternate every other day on who would manage trauma airway issues.”

He adds: “On the heels of COVID-19, there has been additional interest in airway management in the emergency department. And at some of our national meetings, the question of who’s doing what in trauma contexts had come up. So, we decided to get the current lay of the land.”

Their research – “Navigating trauma airway responsibilities in the modern emergency department: A survey of emergency physicians” – was published recently in the American Journal of Emergency Medicine.

→ New Research Poised to Change Oxygen Standards for Trauma Patients

The dawn of emergency medicine

 In emergency departments, endotracheal intubation is the most common method of emergency airway management for patients in respiratory failure (unable to oxygenate, ventilate, or protect their airway). It involves inserting a tube through the mouth or nose and down the patient’s windpipe, or trachea, to establish and maintain an open airway. If needed, oxygen is pumped through the tube to the lungs.

It’s estimated that more than 413,000 endotracheal intubations are performed annually in U.S. emergency departments, representing about 1% of ED visits. They’re done either in case of

trauma that inhibits breathing or for other conditions causing respiratory failure, such as severe pneumonia or a drug overdose.

“I'd say we probably intubate at least one person almost every day in the emergency department,” McIlvain says. “For trauma-specific cases, it’s probably a handful a week.”

Historically, anesthesiologists were responsible for performing emergency airway management of critically ill patients. That tradition dates back to a time before emergency medicine was established as a unique specialty.

“In the house of medicine, emergency medicine is relatively junior,” Brown says. “As a specialty, we really didn’t exist until the 1970s. Until then, physicians from internal medicine and other specialties were moonlighting in the emergency department, and in that setting, the anesthesiologists were experts on all things airway.”

Then, in the 1970s, medical schools began to offer specialized training in emergency medicine. Denver Health, a CU Department of Emergency Medicine clinical partner, established one of the nation’s first residencies in emergency medicine in 1974. Five years later, the American Board of Medical Specialties recognized emergency medicine as a distinct specialty.

→ CU Co-Leads Trial Identifying Method of Emergency Intubation Preoxygenation to Decrease Risk of Hypoxemia and Cardiac Arrest

The primary driver

With the rise of specialized emergency medicine, it has becoming increasingly commonplace for emergency physicians, instead of anesthesiologists, to perform emergency airway procedures in trauma settings, particularly at institutions with emergency medicine residencies.

Brown, McIlvain and Coit knew from previous studies that there was no significant difference in rates of success or complications in endotracheal intubation of trauma patients in emergency departments, whether performed by an emergency physician or an anesthesiologist.

What they didn’t know was how widely the transition to emergency physician responsibility for airway management had been adopted. There hadn’t been a national survey of the current state of affairs in the United States in almost a decade.

The researchers sent a questionnaire to all 317 members of the Society of Academic Emergency Medicine’s airway interest group, of which Brown was chair at the time. They received 39 responses, mostly from emergency physicians at academic centers. Almost all respondents practice at Level I trauma centers.

Nearly 90% of those who replied reported that emergency physicians perform airway management for adult patients in trauma situations at their emergency departments. Specifically, 61.5% said anesthesiologists aren’t present unless asked, and 28.2% said anesthesiologists are present but don’t participate in airway management. Percentages were similar for pediatric trauma patients.

“In our survey, we found that emergency physicians are the primary driver in managing traumatic airway responsibilities in most places across the country,” Brown says.

→ A New Gold Standard for Emergency Airway Management

Advocating for a shift in practice

But, according to the study, 5.2% of respondents said that anesthesiologists still handle airway management for adult patients in their emergency departments. For pediatric patients, the percentage was 5.9%.

“These institutions deviate from the prevailing practice pattern for trauma airway management in emergency departments across the U.S.,” the study concludes. “Considering the body of evidence demonstrating the capability of EPs [emergency physicians] to consistently and successfully manage trauma patients requiring ETI [endotracheal intubation], we advocate for a shift in practice at these outlier institutions. We propose a model in which EPs are the primary physicians responsible for intubating trauma patients while acknowledging the potential for scenarios that may still benefit from collaborative airway management between anesthesiologists and EPs.”

So, given how busy emergency physicians can get, wouldn’t they prefer to hand over airway management to someone else?

“That’s an interesting question, and I would answer it this way,” McIlvain says. “We live in the emergency department, and we are there to take care of every patient who comes through the door. Anesthesia operates in the operating room, which is generally on the second floor or higher in most hospitals. We’d be asking them to leave their space and come into ours to manage a task that we’re more than capable of managing. It seems to me that it wouldn’t be great for patient care to ask someone else to do a procedure on a patient whose care we’re managing. Having one doctor manage that care is probably better for patients overall.”

The authors note there were relatively few responses to their survey representing smaller, rural emergency departments that lack residency programs, so the study does not clearly answer what practices are at such places. But Brown says that at smaller facilities with limited resources, an anesthesiologist might not be available around the clock.

“Having spoken with many colleagues who work in smaller emergency departments, I think there are many places where, when there’s major trauma, no one else is coming to help,” he says. “And so, making sure that our trainees and graduates are fully prepared for managing all aspects of the care of their patients is one of the biggest educational missions that we have.”

Says Coit: “I'm grateful to have had the opportunity to work with Dr. Brown and Dr. McIlvain on this project as a fourth-year medical student. I relied on their expertise to learn about the history and context of emergency airway management in trauma patients while writing the article. And now, as an emergency medicine resident at Denver Health, it has been an incredible experience to learn from them directly in the same situations we were referencing in our work.”