It is an ongoing debate for over a decade whether or not patient should be intubated with or without anaesthesia/muscle relaxants in this setting (Australasian J Emerg Care 1999, 6:5-6). There are no prospective controlled randomised trials to answer this question.

This is a retrospective study which raises the following questions:

• Out of the 1623 intubated patients, 30% were intubated without drugs. What was the indication for intubation with/without drugs. What was the indications for intubation in the two groups?
• What is the severity of injuries in the two groups? What is the cause of death in these patients?
• How many intubation were successful? Are there differences in successful intubations between physicians and paramedics? What were the problems encountered when intubating without drugs (e.g. combative, awake, clinching, etc.)
• What are the drugs used when successful intubating?
• Where was the study performed ? This an area with both ground and helicopter medical services. What is the percentage of the two modalities? What was the indication to use ground or air transport? No details given (problem of confounding factors).

• Only one patient survived and surprisingly this patient had thoracotomy on scene. This is a very interesting case and I wonder whether there is a published case report?
• In the comment made by the authors they try to make a case that paramedics should use drugs for intubation. However from the paper it is unclear whether or not there were survivors when intubated by physicians.