One of the old saws of EMS that continually is repeated like a mantra is “GCS less than 8, intubate.” Much like other EMS myths such as backboarding every patient, withholding pain medications for abdominal pain, and the always popular “treat the patient and not the monitor,” the idea that every patient with altered mental status requires advanced airway management is a complete fallacy.
While I don’t have studies to back my assertion (and really, that’s more the forte and bailiwick of my friend Rogue Medic), I can say that I had a significantly altered patient today who was maintaing their own airway quite well. In fact, the patient’s patent airway was the best part of her clinical presentation. And even with a fifty plus minute transport to a comprehensive facility, she continued to breathe well on her own and maintain her own airway.
The Glasgow Coma Scale was originally developed to measure the neurological status of patients with head injuries. The measurements and decision-making processes associated with treating a head injury are significantly different from treating a patient whose mental status is altered due to a metabolic crisis. Intubation is as much about maintaining an acid/base balance as it is about maintaining a patent airway. Waveform capnography is a huge help, but for the metabolic/medical patient, they may well need to be on a ventilator where settings can be tweaked and adjusted. In other words, intubating a medical patient may well be a procedure that should wait until lab values are obtained and the patient can go on a ventilator.
It’s way past time to embrace clinical decision making rather than rote memorization of protocols and old wives’ tales passed down from crew to crew. It’s definitely time to base the paramedic’s identity on knowledge and clinical judgment rather than continually clinging to certain skill sets. And for the medical patient, I think clinging to the Glasgow Coma Scale to measure the patient’s neurological status is the equivalent of using a screwdriver to put nails in wood.