Page 113 - JSOM Winter 2023

which is another challenge. Such training volumes are not fea- 2. Freund Y, Bloom B. Video laryngoscopy for intubation – time for
sible in a pre-deployment, just-in-time training model, and de- a new paradigm? N Engl J Med. Aug 3 2023;389(5):472–473.
ploying medical officers to these roles with inadequate training 3. Pourmand A, Terrebonne E, Gerber S, Shipley J, Tran QK. Effi-
is unacceptable. Indeed, first-pass success with VL is superior cacy of video laryngoscopy versus direct laryngoscopy in the pre-
hospital setting: a systematic review and meta-analysis. Prehosp
to that with DL at all levels of training, but the difference is Disaster Med. Dec 14 2022:1–11.
more pronounced among operators with less intubation ex- 4. Vargas M, Servillo G, Buonanno P, et al. Video vs. direct laryn-
16
perience. This finding was even more pronounced when as- goscopy for adult surgical and intensive care unit patients requir-
sessing relatively novice intubators, which is relevant to the ing tracheal intubation: a systematic review and meta-analysis of
early resuscitative trauma mission for the deployed Military randomized controlled trials. Eur Rev Med Pharmacol Sci. Dec
2021;25(24):7734–7749.
Healthcare System. Novice intubators (<25 reported intuba- 5. Schauer SG, Long BJ, Rizzo JA, et al. A conceptual framework for
tions) using VL had similar first-pass success to experienced non-military investigators to understand the joint roles of medical
intubators (>200 intubations) using DL in the Prekker study. care in the setting of future large scale combat operations. Pre-
1
In other words, VL technology can close the gap between nov- hosp Emerg Care. 2023;27(1):67–74.
ice and experienced intubators. The need for materiel solutions 6. Schauer SG, Naylor JF, Maddry JK, et al. Prehospital airway man-
agement in Iraq and Afghanistan: a descriptive analysis. South
to optimize airway management among less experienced medi- Med J. Dec 2018;111(12):707–713.
cal officers will only accelerate if the U.S. military enters large- 7. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway
scale combat operations (LSCO), given the physician supply procedures performed in trauma patients by ground forces in Af-
and demand mismatch to the massive number of patients that ghanistan. J Trauma Acute Care Surg. Jul 2018;85(1S Suppl 2):
would occur (as the authors previously described). 17 S154–S160.
8. Schauer SG, Naylor JF, Chow AL, et al. Survival of casualties un-
dergoing prehospital supraglottic airway placement versus crico-
VL technology represents a prudent stop-gap measure that the thyrotomy. J Spec Oper Med. Summer 2019;19(2):91–94.
U.S. military must implement before the next conflict occurs to 9. Schauer SG, Naylor JF, Hill GJ, Arana AA, Roper JL, April MD.
ensure adequate contracting, logistical support, and fielding. Association of prehospital intubation with decreased survival
The Prekker study noted a number needed to treat (NNT) of among pediatric trauma patients in Iraq and Afghanistan. Am J
Emerg Med. Apr 2018;36(4):657–659.
seven, meaning that for every seven patients undergoing intu- 10. Schauer SG, April MD, Tannenbaum LI, et al. A comparison of
bation with a VL device, one will derive benefit. We can apply prehospital versus emergency department intubations in Iraq and
this NNT to real-world data. For example, lack of first-pass Afghanistan. J Spec Oper Med. Summer 2019;19(2):87–90.
success substantially increases the risk of hypoxic and other car- 11. Schauer SG, April MD. A comparison of combat casualty out-
diovascular events; a recent systematic review found that nearly comes after prehospital versus military treatment facility airway
one in three emergency intubations are at risk for such events. management. Med J (Ft Sam Houst Tex). Jan–Mar 2023;(Per
18
23-1/2/3):9–96.
The authors’ recent study assessing Role 1 interventions from 12. Schauer SG, Hudson IL, Fisher AD, et al. Improving outcomes as-
2007 to 2019 found that of the 25,849 casualties, 1,147 were sociated with prehospital combat airway interventions: an unre-
intubated prehospital. Using the NNT, 164 casualties would alized opportunity. J Spec Oper Med. Mar 15 2023;23(1):23–29.
19
have derived direct benefit from VL intervention. The number is 13. Gerhardt RT, De Lorenzo RA, Oliver J, Holcomb JB, Pfaff JA.
likely far greater, given the ongoing challenges with prehospital Out-of-hospital combat casualty care in the current war in Iraq.
Ann Emerg Med. Feb 2009;53(2):169–74.
data capture that the authors have previously described. 20,21 A 14. Buis ML, Maissan IM, Hoeks SE, Klimek M, Stolker RJ. Defining
data-driven approach to medical planning supporting current the learning curve for endotracheal intubation using direct laryn-
irregular warfare missions and future LSCO missions leaves goscopy: A systematic review. Resuscitation. Feb 2016;99:63–71.
no question: the Department of Defense needs to prioritize the 15. Schauer SG, April MD, Knight RM, et al. Opinion: The risks of pro-
fielding video laryngoscopy for acute airway intubations. longed casualty care for conventional forces in large-scale combat
operations. Task and Purpose. Recurrent Ventures Inc; 2023. 9 May
2023. https://taskandpurpose.com/opinion/risks-prolonged-casualty
Author Contributions -care-large-scale-combat-operations/ Accessed 25 June 2023.
SGS performed the initial drafting and the revisions. The re- 16. Garcia SI, Sandefur BJ, Campbell RL, et al. First-attempt intuba-
maining authors provided critical revisions and key subject tion success among emergency medicine trainees by laryngoscopic
matter expertise. All authors contributed substantially to this device and training year: a national emergency airway registry
editorial. All authors read and approved the final manuscript. study. Ann Emerg Med. Jun 2023;81(6):649–657.
17. Schauer SG, April MD. Large-scale combat operations and impli-
cations for the emergency medicine community. Ann Emerg Med.
Disclaimer Nov 2022;80(5):456–459.
Public Affairs Office approved. The views expressed in this 18. Downing J, Yardi I, Ren C, et al. Prevalence of peri-intubation
article are those of the authors and do not reflect the offi- major adverse events among critically ill patients: a systematic re-
cial policy or position of the U.S. Army Medical Department, view and meta analysis. Am J Emerg Med. Sep 2023;71:200–216.
Department of the Army, Department of Defense, or the U.S. 19. Schauer SG, Naylor JF, Fisher AD, et al. An analysis of 13 years of
Government. prehospital combat casualty care: implications for maintaining a
ready medical force. Prehosp Emerg Care. May–Jun 2022;26(3):
370–379.
Disclosures 20. Nissley LE, Rodriguez R, April MD, Schauer SG, Stevens GJ.
The authors have indicated they have no financial relation- Occam’s razor and prehospital documentation: when the simpler
ships relevant to this article to disclose. solution resulted in better documentation. Med J (Ft Sam Houst
Tex). Jan–Mar 2023;(Per 23-1/2/3):81–86.
Funding 21. Schauer SG, April MD, Naylor JF, et al. A descriptive analysis of
None. No other publication or presentation of study data. data from the Department of Defense Joint Trauma System Pre-
hospital Trauma Registry. US Army Med Dep J. Oct–Dec 2017;
(3–17):92–97.
References
1. Prekker ME, Driver BE, Trent SA, et al. Video versus direct laryn- Keywords: airway; military; video; laryngoscopy; trauma
goscopy for tracheal intubation of critically ill adults. N Engl J
Med. Aug 3 2023;389(5):418–429. PMID: 38029417; DOI: 10.55460/LZ5V-QDH4

Fielding Video Laryngoscopy | 111